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Policy No:  116

Originally Created: 11/01/2016

Section:  Modifiers

Last Reviewed: 09/01/2018

Last Revised: 11/01/2016

Approved: 09/20/2018

Effective: 11/01/2018

This policy applies only to outpatient hospital and ambulatory surgical centers (ASC).

Definitions

Current Procedural Terminology (CPT®) Modifier 73 - Discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia

Used due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of modifier 73.

CPT Modifier 74 - Discontinued outpatient hospital/ASC procedure after the administration of anesthesia

Used due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of modifier 74.

Policy statement

Our health plan reimburses modifiers 73 and 74 in following manner:

  • Procedure code(s) submitted with modifier 73 will be reimbursed at 50% of the allowable amount. Only the primary intended procedure should be submitted
  • Procedure code(s) submitted with modifier 74 will not be reduced

Discontinued radiology procedures that do not require anesthesia may not be reported using modifiers 73 and 74.

The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

Procedure codes for any other procedure not performed at all should not be additionally reported.

Procedure code/modifier combinations that are considered not valid for our health plans use will be denied.

References

Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File

American Medical Association. "Appendix A: Modifiers" Current Procedural Terminology (CPT). AMA Press

Cross References

Modifier 53; Discontinued Procedure

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.