Effective Date:

May 23, 2021

Purpose:

This policy provides guidelines of reimbursement for the use of modifier –73 for both professional and outpatient facility claims.

Scope:

Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Definitions:

Modifier –73: Used to report discontinued outpatient/hospital ambulatory surgical center (ASC) procedures prior to the administration of anesthesia. Modifier -73 should be used due to extenuating circumstances or situations in which the member’s well-being is threatened.

Policy:

Modifier –73 is only appropriate for procedures requiring anesthesia for outpatient/hospital ASCs and should not be used by physicians. To report modifier -73, the patient must be prepared for the procedure and taken to the room where the procedure is to be performed. Documentation must show a discontinuation of a procedure with a noted extenuating circumstance or an unexpected change in the member’s well-being.

Modifier –73, when appropriately used, will reimburse at 50% of the allowable rate.

If a claim is received with modifier –73 and the same procedure code was previously submitted on a professional claim with modifier –52 (reduced services), Horizon NJ Health shall deny the outpatient facility claim.

If a procedure performed in an outpatient/hospital ambulatory surgical center (ASC) has a modifier –73 implying a discontinued service prior to anesthesia administration, a separate bill for anesthesia should not be submitted. Should a procedure have a modifier –73 affixed, the associated anesthesia claim(s) shall deny.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:

Horizon NJ health will consider for reimbursement claims affixed with modifier –73 at 50% of the allowable rate.

Horizon NJ Health will not consider for reimbursement anesthesia claims (CPT codes 00100 – 01999) performed in an outpatient/hospital ambulatory surgical center (ASC) when the associated procedure has a modifier –73 affixed to it.

Horizon NJ Health will not consider for reimbursement procedures without a modifier –73 when the same procedure code has been billed on a professional claim for the same date of service with modifier –52.

Horizon NJ Health will not consider for reimbursement claims affixed with modifier –73 when billed on professional claims.

Resources:

Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual, Chapter 4, Section 20.6.4

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.