First Coast identified claims reporting modifier 53 (discontinued procedure) without supporting documentation or an explanation in the narrative of the claim. To avoid claim denials and future appeals due to these incorrect claim submissions, we’re providing guidance on how to properly submit a claim when applying this modifier.

Under certain circumstances, the provider may elect to terminate a surgical or diagnostic procedure due to circumstances that may threaten the well-being of the patient. 

Example: Stopped early due to inability to pass the pipelle through the cervix.

Appropriate usage

• Unusual (discontinued) circumstances
• A discontinued procedure after induction of anesthesia
• Append modifier to the discontinued procedure’s CPT code

Inappropriate usage

• To report the elective cancellation of a procedure
• Procedure discontinued prior to the anesthesia being induced
  • Note: Consult Modifier 73
• When used on E/M services
• Do not use on time-based procedure codes (i.e., anesthesia, critical care and psychotherapy)
• For outpatient hospital or ambulatory surgical center services

Supporting documentation 

• You can write additional information to support the modifier in the narrative of claim
• If data cannot be written in the narrative, you must submit documentation. Please see below for details on providing documentation:
  • For non-medical review ADRs, try PWK which is a process that allows you to submit documentation with an initial claim. Learn more here
• Supporting documentation should:
  • State when the procedure was started
  • Explain why the procedure was discontinued
  • Notate the percentage of the procedure that was performed 

References: 

• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, section 30.1
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, section 60.2
• Change request CR9317 - New Values for Incomplete Colonoscopies Billed with Modifier 53