Wednesday, August 11, 2010

Medicare modifier 53 - discontinued procedure

Modifier 53 Discontinued Procedure (professional services only)

Instructions

This 53 modifier allows the physician community to state the surgical procedure was discontinued due to extenuating circumstances or a threat to patient well-being.  

Correct Use

    Append in first pricing position
    Under certain circumstances, physician may elect to terminate surgical or diagnostic procedure
        Surgical or diagnostic procedure started and discontinued by physician
        Prior to or after anesthesia is administered
    Bill Medicare the percentage of service completed (see second example below)
        Medicare Claims Processing System does not automatically reduce payment

Incorrect Use

    Inappropriate with E/M or anesthesia codes
    Do not use to report elective procedure cancellation, in the operating suite, prior to patient's anesthesia induction and/or surgical preparation
    Inappropriate to use for Ambulatory Surgery Center (ASC) or hospital facility claims
         Use facility modifiers 73 or 74
    Do not confuse with "reduced procedure" modifier 52

Definition:

• Indicates the physician elected to terminate a surgical or diagnostic procedure due to the patient’s well-being.

Appropriate Usage:

• A discontinued procedure after induction of anesthesia

• Report modifier 53 in the first modifier field when appended to procedure code 45378, G0105 and G0121

• Bill modifier 53 with the CPT code for the service furnished


• Modifier 53 indicates the physician elected to terminate a surgical or diagnostic procedure due to extenuating circumstances, or those threatening the well-being of the patient.

• Append modifier 53 to the CPT code for the discontinued procedure.

• Documentation should reflect the extent of the procedure performed and the reason the procedure was discontinued.

• It may be reported for both office and hospital based procedures.

• It should not be reported for elective cancellation of a procedure prior to anesthesia induction or surgical prep.

• It should not be used to when a surgical approach is unsuccessful and another approach during the same session is completed.


Inappropriate Usage:

• On an Evaluation and Management Procedure Code
• Discontinued surgeries prior to the anesthesia being induced
• When appended to an E/M procedure code
• Do not use on time-based procedure codes (i.e. critical care and psychotherapy)

Facts:

Procedure codes 45378-53, G0105-53, and G0121-53 have their own fee schedule amounts. All other services billed with 53 are subject to carrier medical review and priced by individual consideration.

Supporting documentation should:

• be available upon request
• state the procedure was started
• why the procedure was discontinued
• state the percentage of the procedure was performed

Guidelines usage of Colonoscopy procedure 

According to CPT instruction, prior to calendar year (CY) 2015, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append Modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states:

“When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”

Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specified values in the Medicare Physician Fee Schedule (MPFS) database for the following codes:

* 44388-53 (colonoscopy through stoma);

* 45378-53 (colonoscopy);

* G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk; and

* G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Effective for services performed on or after January 1, 2016, the MPFS database will have specific values for the codes listed above. Given that the new CPT definition of an incomplete colonoscopy also include colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with Modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.



Billing and reimbursement

For Network Health to consider reimbursing a discontinued service, providers must append Modifier 53 to the appropriate claim service code. Providers can attach Modifier 53 to one code per operative session. Providers cannot use Modifier 53 for elective procedure cancellation prior to a member’s anesthesia induction and/or surgical preparation in the operating suite. Providers cannot use Modifier 53 after converting a laparoscopic or endoscopic procedure to an open procedure, or after changing or converting a procedure to a more extensive procedure. Network Health requires documentation to make a payment determination.


DESCRIPTION:

The term discontinued procedure designates a surgical or diagnostic procedure provided by a physician or other health care professional that was less than usually required for the procedure as defined in the Current Procedural Terminology (CPT) book. Discontinued procedures are reported by appending modifier 53.

Modifier 53 is used when a procedure was actually started, but was discontinued before completion due to extenuating circumstances or those that threaten the well-being of the patient.



REIMBURSEMENT INFORMATION:

Reimbursement of discontinued procedures with Modifier 53 is 50% of the allowable amount for the primary unmodified procedure. Multiple procedure reductions may also apply.

If based on post payment clinical records review, Modifier 53 was not reported when indicated, Florida Blue will apply appropriate edit and adjust payment consistent with this policy.

Exception: For procedure codes 44388, 45378, G0105, & G0121, CMS publishes relative values (RVUs) for modifier 53. Therefore, the allowance for these procedures will be based on the RVU rate via the fee schedule and an additional 50% reduction is not applied.

Modifier 53 is not used to report the elective cancellation of a procedure, prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.
For procedures that are partially reduced or eliminated at the physician’s direction, see the Reduced Services Policy describing the use of modifier 52.


BILLING AND CODING:

According to the Centers for Medicare and Medicaid Services (CMS) and CPT coding guidelines, modifier 53 should be used with surgical codes or medical diagnostic codes.

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