Modifier 53

Modifier 53 (2022) Description, Uses, Guidelines & Examples

Modifier 53 appends to the service when the physician discontinues or terminates the procedure or service due to unavoidable circumstances. 

Modifier 53 Description

Modifier 53 is appropriate to report the diagnostic or surgical procedure when the physician discontinues the practice under unavoidable circumstances. It may terminate due to extenuating circumstances or life-threatening conditions of the patient. 

Modifier 53 is inappropriate to report when the hospital outpatient bill the service that was partially reduced or canceled due to extenuating circumstances or life-threatening condition of the patient before or after the administration of anesthesia. Reporting with modifiers 73 and 74 for ASC hospital outpatient use is appropriate. 

Modifier 53 is inapplicable to report with elective cancellation of a procedure before the anesthesia administration or preparation in the operating suite. 

Modifier 53 is inapplicable to report with anesthesia codes. In contrast, the fee reduction of the procedure may impact the payment of the anesthesia codes. The cost reduction may not apply to gastrointestinal services with unique Relative Value Units (RVUs) when bills in combination with modifier 53 such as G0121-53, G0105-53, 45378-53, 44388-53.

CPT code 45378 reports that it is appropriate when the physician performs diagnostic colonoscopy (45378) and cannot advance the colonoscopy to the cecum or colon-small intestine anastomosis due to unforeseen circumstances to report CPT code 45378 with modifier 53.

The CMS Physician Fee Schedule files the allowable amount for separate RVU/pricing for 45378-53, which is the 50 % RUVs of the total amount. The insurance or third party may pay 50 % of the allowable amount. If it may not lists on the PFS schedule, the cost will consider manually. 

53 modifier

What Is Modifier 53?

Modifier 53 usually adds to the services when the physician terminates or eliminates the service under certain circumstances. The usual services bill without modifier 53 because of no understanding about the events when it is appropriate. 

Modifier 53 is appropriate when the service meets the criteria of extenuating circumstances or may have a life threat to the patient’s life. It must write in the documentation that the procedure or service begins and discontinues due to unfortunate circumstances.

The insurance or third-party payer may reimburse the service for the procedural preparation. It also may lead to full reimbursement when physicians later reperform the same procedure to the same patient. 

When To Use Modifier 53

Modifier 53 is applicable for the service when the physician decides to terminate the surgical or diagnostic procedure under extenuating circumstances. 

The service must have begun to append modifier 53 with the procedure code and terminated or discontinued later.

Modifier 53 is appropriate to attach with the service before and after administering anesthesia when the physician eliminates the service due to unavoidable circumstances. 

The documentation indicates the percentage of work completed during the procedure when bills to Medicare insurance. They may not reduce the payment automatically and may review this service manually.  

Modifier 53 should report first when listed on the claim, such as two modifiers required for the procedure or service 53 and 59. It may represent CPT code XYZ-53, 59.

Modifier 53 Guidelines

The physician or other skilled professional terminates the procedure due to extenuating circumstances and may have threats to the patient’s life, and it is appropriate to report with modifier 53.

If multiple procedures plan for the patient in one operative session, the service terminates at an early stage. It is appropriate to report modifier 53 with only one procedure code instead of all the other procedures. 

Modifier 53 is inappropriate to attach with the services when the procedure terminates before the anesthesia administration or surgical preparation in the operating suite. 

53 represents the suspension of physician & professional services only and do not applicable for use by outpatient hospital services or ASCs.   

Modifier 52 is inappropriate to report to Ambulatory Surgical Center (ASC) and adequate to bill with modifiers 73 and 74 for discontinued procedures.

Modifier 53 is irrelevant when the physician or other skilled professional performs the evaluation and service (99201-99499). It is appropriate to report with E/M modifiers such as 24, 25, 57, etc. 

Modifier 53 does not confuse with modifier 52, and it is appropriate to report with reduced service, not for the terminated procedures. 

The modifier is inappropriate to bill for the laparoscopic or endoscopic procedure when this service converts to an open or more extensive surgical procedure. It is appropriate to report with the more extensive procedure code. 

53 indicates only the professional discontinued service of the physician, and it is inappropriate to report for the facility use and ASC hospital outpatient services. 

Modifier 53 is inappropriate to report with time-based codes such as critical care codes 99281-99285.

The insurance or third-party payer may reimburse 25 % of the allowable amount. The reduction may apply to this 25% acceptable amount when other pricing modifiers attach to services such as Assistant physicians. 

The insurance may pay reimbursement manually if not listed in the physician fee schedule with 53. If multiple procedures may perform on the same day, then additional reduction applies to the service with considerable procedures reduction, such as removal and reinsertion of IUD (58300-53-51).

The insurance or third party may allow 25-30% when the physician terminates the procedure after the anesthesia administration. It may cover the pre-operative RVU and a portion of the intraoperative RVU. 

The insurance or third party may pay manually if the service nears the complete procedure performed and documented. 

Modifier 53 is inappropriate to report with the services that the physician electively terminates the procedure, not due to extenuating circumstances. 

Modifier 53 Examples

The following are the examples when the modifier 53 appends with the service:

Example 1

A 34-year-old female presents to the physician’s office with acute pelvic pain and menorrhagia. The patient denies abdominal pain, chest pain, respiratory problems, dizziness, and nausea. 

She took no medication for the pain and was 7 out of 10 in severity. The physical exam reveals some palpable abnormality in the female genital region. 

The physician orders a transabdominal and pelvic exam. It shows a mass in the endometrial regions. He consulted with the oncologist and suggested an endometrial biopsy when the physician started the procedure and saw uterine perforation risk.

He immediately terminated the procedure because of the threat to the patient’s life, and it is appropriate to report this service 58100 with modifier 53.

Example 2

A 51 years-old male has no past medical history presented to ED (Emergency Dept) with lower abdominal x 5 days on and off, primarily constant now, burning in nature, 9 out of 10, and worse on exertion. He is unable to take any food. 

The patient Denies shortness of breath, sweating, nausea, vomiting, cough, hemoptysis, palpitations, leg pain, or swelling: no excessive belching, flatus, diarrhea, constipation, fever, or chills. 

Physical exams revealed that pain is related to the colon despite heart-related and differential dx being Colitis. Diagnostic studies like CT and MRI of the abdomen and pelvis revealed that the large intestine is severely inflamed.

The doctor consulted with a gerontologist and suggested a Colonoscopy to treat the inflamed large intestine. The patient placed an appointment with a gastroenterologist for a colonoscopy.  

The physician begins the procedure and cannot perform the colonoscopy due to hypothermia starting with the patient. He terminated the operation. It is appropriate to report with modifier 53.

Example 3

A 49-year-old male presents to the office with no past medical and family history for the follow-up of pulmonary nodules. 

The patient denies chest pain, headache, numbness, tingling, urinary problem, nausea, vomiting, and diarrhea.

A physical exam revealed an unremarkable study of all the other systems. Physicians ordered a CT chest, X-ray, and lab test to evaluate pulmonary nodule.

The Radiologist performs the CT scan of the chest with contrast. When the physician injects the contrast into the patient’s body, it starts an allergic reaction and starts vomiting. He terminates the procedure due to an allergic reaction to the contrast. It is appropriate to report with modifier 53 with CPT code 71260. 

Modifier 52 vs 53

Modifier 52 is appropriate when the physician performs the service partially or reduced due to unfortunate circumstances. They do not execute all components of the CPT code for the service and eliminates by the physician.

It is inapplicable to append with unlisted procedure codes because no service description mentions in the procedure.

The service may reduce due to the absence of either surgical, accidental, or congenital body parts, such as if the patient had a history of right mastectomy and now have a procedure on the left breast.

The CPT code may apply to both sides of the breasts, and no other unilateral code is present for the service. It is appropriate to report with modifier 52. 

In contrast, Modifier 53 is appropriate when the physician terminates or discontinues the service or procedure due to extenuating circumstances for the patient’s well-being. The extenuating service may be like the patient started severe shortness of breath or allergic reaction after getting any medication during the procedure and have a threat to the patient’s life. 

Inappropriate Usage Of Modifier 53

Don’t use the 53 modifier with:

Evaluation and management (E/M) services

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

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.

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.

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