For Providers

Reimbursement Policies & Guidelines

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Modifier 53

Effective Date: May 10, 2016

Purpose:
To appropriately price all codes specifically identified in Core and to establish appropriate configuration in Networx, to verify and update as needed, the On-line information (OLH & OLI) regarding the use of this modifier, and provider education/communication needs to be created and distributed to ensure appropriate billing and use of this modifier.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB.

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
Modifier -53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.

Policy:
Modifier 53 - Discontinued procedure Reimbursed at 25% of the fee schedule/allowable amount.

Procedure:
This modifier can be associated with many CPT codes not currently priced in Core, therefore, manual adjudication will be necessary. OLI and OLH will need to be updated for the appropriate payment of this code.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.
  • Should not be appended to E&M Codes
  • Should not be appended to time-based Codes i.e. Anesthesia, psychotherapy or critical care.