Modifier 53 could almost be stated to as a forgotten modifier; practices forget or just never find out how to appropriately use it. This is often partially because there’s no set definition for ‘extenuating circumstances,’ leaving it susceptible interpretation and diminishing appropriate use. It’s especially unfortunate how disused modifier 53 is, because by not using it, practices miss out on partial payment for the work that was done by getting reimbursed for the expense of procedural prep. Using modifier 53 when the procedure is discontinued also ensures the instance for the provider to completely bill that very same procedure later, when it can be performed in its entirely.
Modifier 53
As noted earlier, the qualifying discontinued service codes for modifier 53 are very specific. CPT® Appendix A states, “Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier ‘53’ to the code reported by the physician for the discontinued procedure.”
Modifier 53 – Discontinued procedure
This modifier must be submitted within first modifier field.
Under certain conditions, the provider may choose to terminate a surgical or diagnostic procedure. It’s going to be necessary to specify that a surgical or diagnostic procedure was started, but discontinued due to extenuating conditions that threaten the well-being of the patient. This circumstance must be informed by adding CPT modifier 53 to the code reported by the provider for the discontinued procedure.
Incorrect use:
- Do not use modifier 53 for an elective cancellation of the procedure.
- Do not use to report the elective cancellation of a procedure before to the patient’s anesthesia induction and/or surgical preparation within operating suite.
- Do not use on an Evaluation and Management Procedure Code.
- Do not use on time-based procedure codes. (i.e., critical care and psychotherapy).
- Do not submit CPT modifier 53 when a laparoscopic or endoscopic procedure is converted to an open procedure.
Appropriate use:
- This modifier is often used with both diagnostic and surgical CPT codes.
- Bill modifier 53 with the CPT code for the service furnished.
- This modifier is used to report a treatment or procedure when the treatment or procedure is discontinued after anesthesia is administered to the patient.
Starting in 2015, and still in 2020, the CPT® guidelines state, “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.”
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