Imagine you are a surgeon and start preparing for a routine procedure. You start by applying the anesthesia and taking the patient’s vitals. However, you have to stop midway because the patient’s blood pressure suddenly plummets. These types of scenarios happen more often than you think. They lead to revenue loss for healthcare providers because they don’t know how to bill for such situations.
The solution is modifier 53. But what is it? And can you use it practically? Well, that is what this blog is all about. We will discuss everything about modifier 53, including its definition and practical examples. So, let’s get started.
Modifier 53 Description
It is a two-digit code appended to CPT codes. It is used to indicate that a surgical or diagnostic procedure was initiated but discontinued or left in the process (after anesthesia administration) due to extenuating and unfavorable circumstances, which are usually beyond the control of a healthcare provider.
The situations in which modifier 53 is used typically involve risks to the patient’s health, such as adverse reactions, unstable conditions, or technical barriers that arise after the procedure is initiated. A key thing to note here is that, unlike situations where cancellations occur before anesthesia delivery or preparation of the procedure, modifier 53 is only applicable when the process is started and left underway for safety reasons.
The use of this modifier helps inform the insurance payers that the procedure was partially performed. This allows physicians to seek partial reimbursements. The amount of reimbursement in this case varies from case to case. But generally, it is around 25% of the actual fee.
What is Modifier 53 Used for?
To better understand how to use this modifier, let’s look at some common scenarios. These examples reflect challenges faced by healthcare providers in real settings and how this modifier helps them get fair compensation.
Discontinued Cataract Surgery
An elderly patient is diagnosed with cataracts. The ophthalmologist suggests a cataract extraction surgery and schedules it. The ophthalmologist starts the surgery at the scheduled date and time. However, in mid-procedure, the patient experiences a severe allergic reaction to the anesthesia. The eye swells (angioedema), making it extremely dangerous to continue the procedure.
The surgery is abandoned, and modifier 53 is added to the claim, documenting the medical necessity of the discontinuation.
Cancelled Bronchoscopy
A patient visits a pulmonologist due to a persistent cough and abnormal chest X-rays. To diagnose the situation, the pulmonologist gives anesthesia to the patient and starts the bronchoscopy. However, during the procedure, the patient undergoes a severe bronchospasm. This makes it difficult for the patient to breathe.
The pulmonologist immediately stopped the procedure to tackle the respiratory emergency. Now, to bill for the halted bronchoscopy, he used modifier 53 in the insurance claim.
Accurate Usage Guidelines for Modifier 53
It is essential to use modifier 53 in the right situations. Otherwise, there is a high chance your claim will get denied. Here is a detailed look at when and how to apply it:
When To Use Modifier 53
- Only to be used when the procedure is stopped due to sudden and unexpected circumstances, usually involving a medical emergency. Examples of this can be equipment malfunctions or poor anatomical conditions.
- It should be used when patient safety is at risk and continuing the procedure is more harmful than stopping it.
- In most cases, the procedure should begin after administering anesthesia or making an incision.
Please note that this modifier is only for physician services (professional billing). Facilities like ambulatory surgery centers (ASCs) or outpatient hospitals use Modifiers 73 or 74 instead (institutional billing).
When NOT To Use Modifier 53
- Elective Cancellations: If a patient opts out before the procedure starts, this modifier does not apply.
- Pre-Procedure Stops: Cancellations before anesthesia or prep are ineligible.
- Procedure Conversions: If a laparoscopic surgery switches to an open approach, use the completed procedure’s code, not modifier 53.
- Non-Surgical Codes: It does not apply to evaluation and management (E/M) services or time-based codes like critical care.
Documentation Essentials
Like other modifiers, modifier 53 requires extensive documentation to justify the discontinuation. No insurance provider is going to take your word as justification. So, make sure to include:
- Reason for Stopping: Specify the medical or technical issue that led to discontinuation. For example, you can add a procedure aborted due to the patient’s blood pressure dropping to 80/50.
- Progress Made: Note how far the procedure advanced (e.g., “25% of colonoscopy completed”).
- Supporting Records: To strengthen your case, also make sure to add operative notes or other logs, such as vital signs.
Modifier 53 vs. 52
Modifiers 53 and 52 indicate incomplete procedures, so billers often confuse them. However, both modifiers have distinct purposes. Mixing them up can lead to underpayment or denials, so let’s clarify the differences.
Modifier 53: Discontinued Procedure
- Purpose: As discussed above, this modifier indicates a procedure started but stopped due to patient safety or extenuating circumstances.
- Trigger: Beyond the provider’s control (e.g., unstable vital signs).
Modifier 52: Reduced Services
- Purpose: The modifier 52, on the other hand, is used when a procedure was started but intentionally reduced or limited in scope. This is done at the discretion of the healthcare provider. It is mostly used within radiology billing.
- Trigger: Clinical choice, not an emergency (e.g., a shorter exam than planned).
| Aspect | Modifier 53 | Modifier 52 |
|---|---|---|
| Reason | Patient risk or complications | Provider’s decision |
| Control | Uncontrollable | Controlled |
| Payment | Partial work done | Reduced for limited service |
| Anesthesia | Often post-anesthesia | Typically pre- or no-anesthesia |
Final Thoughts
The modifier 53 is a great tool to ensure that you get partial reimbursements for procedures started but left incomplete due to a medical necessity. By using it correctly, you can significantly reduce your claim denials and improve revenue generation.
This guide provides all the necessary information to help you use this modifier correctly. So, read this blog thoroughly, and if you still have some confusion, feel free to reach out to us or outsource medical billing and coding to NeuraBill, for tailored solutions.
