United HealthCare - Discontinued Procedure Policy

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. It is not appropriate to use modifier 53 if a portion of the intended procedure was completed and a code exists which represents the completed portion of the intended procedure.

Reimbursement Guidelines

Under certain circumstances such as a serious risk to the patient's well-being, a surgical or diagnostic procedure is terminated at the physician or other health care professional's direction. Under these circumstances the procedure provided should be identified by its usual procedure code and the addition of modifier 53 (discontinued procedure) signifying that the procedure was started but discontinued. This provides a means of reporting the discontinued procedure leaving the identification of the basic service intact.

According to the Centers for Medicare & Medicaid Services (CMS) and CPT coding guidelines, modifier 53 should be used with surgical codes or medical diagnostic codes. Modifier 53 should not be used with:

1. Evaluation and management (E/M) services

2. Elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite.

3. When a laparoscopic or endoscopic procedure is converted to an open procedure or when a procedure is changed or converted to a more extensive procedure.

UnitedHealthcare's standard for reimbursement of discontinued procedures with modifier 53 is 25% of the allowable amount for the primary unmodified procedure. Multiple procedure reductions will still apply.

Reference: UHC's Discontinued Procedure Policy and for procedures that are partially reduced or eliminated at the physician's direction, see UnitedHealthcare's Reduced Services (Modifier 52) policy.