CurrentBlue Cross Blue Shield - MainePolicy G-10033

Modifiers 52, 53, 73, and 74: Reduced and Discontinued Services

Defines reimbursement treatment for reduced or discontinued services when billed with modifiers 52, 53, 73, and 74 for AMH Health (Medicare Advantage) members; applies to professional providers and facilities submitting claims under this payer.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 52, 53, 73, and 74: Reduced and Discontinued Services

Policy CodePolicy G-10033

Change TypeNo material change

Effective DateDec 14, 2023

Next Review Date

Key ActionClaims appended with Modifiers 52, 53, 73, and 74 may be reimbursed per this policy; the payer reserves the right to perform post-payment review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%reimbursement reduction for Modifiers 52 and 53

100%reimbursement for Modifier 74

subjectpost-payment review

professional & facilityapplicability

Reimbursement for Reduced or Discontinued Services

Reimbursement criteria for reduced/discontinued services

Reimbursement rules when reduced or discontinued service modifiers are submitted:

Modifier 52 and Modifier 53 generally result in reimbursement reduced to 50% of the applicable fee schedule or contracted/negotiated rate.

Modifier 73 generally results in reimbursement reduced to 50% of the applicable fee schedule or contracted/negotiated rate and is intended for outpatient hospital/ASC procedures cancelled after surgical preparation but before administration of anesthesia; Modifier 73 is not applicable for professional provider billing.

Modifier 74 is used when a procedure is discontinued after administration of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted); reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate; Modifier 74 is not applicable for professional provider billing.

Do not report Modifiers 52 or 53 on time-based evaluation and management (E/M) and consultation codes.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifiers 52, 53, 73, and 74: Reduced and Discontinued Services

Policy CodePolicy G-10033

Change TypeNo material change

Effective DateDec 14, 2023

Next Review Date

Key ActionClaims appended with Modifiers 52, 53, 73, and 74 may be reimbursed per this policy; the payer reserves the right to perform post-payment review.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Applicable Modifiers and Reimbursement Details

Modifier 52ModifierCovered

Modifier 52

Reduced Services - Reimbursement is reduced to 50% of the applicable fee schedule or contracted/negotiated rate. Do not report Modifier 52 on time-based evaluation and management (E/M) and consultation codes.

Modifier 53ModifierCovered

Modifier 53

Discontinued Procedure - Reimbursement is reduced to 50% of the applicable fee schedule or contracted/negotiated rate. Modifier 53 is not applicable for facility billing and is not valid when billed on time-based E/M codes.

Modifier 73ModifierCovered

Modifier 73

Discontinued Outpatient Hospital/ASC Procedure Prior to the Administration of Anesthesia - Reimbursement is reduced to 50% of the applicable fee schedule or contracted/negotiated rate. Modifier 73 is not applicable for professional provider billing.

Modifier 74ModifierCovered

Modifier 74

Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia - Reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate. Modifier 74 is not applicable for professional provider billing.

Reimbursement reduction threshold

Reimbursement reduction threshold50% reduction applies to Modifiers 52, 53, and 73 of the applicable fee schedule or contracted/negotiated rate unless otherwise stated

Modifier 74 reimbursementReimbursement is 100% of the applicable fee schedule or contracted/negotiated rate for Modifier 74

Applicability to billing typesModifier 53 and 73 have billing applicability limits: Modifier 53 is not applicable for facility billing; Modifier 73 is not applicable for professional provider billing

Billing and Review Requirements

Documentation Required

Claims with Modifiers 52/53/73/74 are subject to post‑payment review

Claims submitted with Modifiers 52, 53, 73, and 74 may be reimbursed under this policy, but the payer reserves the right to perform post‑payment review. Providers should retain and make available supporting documentation for any reduced or discontinued services in case of review; when assistant surgeons or multiple procedures are involved, applicable assistant‑surgeon and multiple‑procedure rules and fee reductions also apply.

Retain documentation supporting the clinical reason for the reduced or discontinued service.
Be prepared to provide records if requested during post‑payment review.
Apply assistant surgeon and multiple‑procedure rules and fee reductions when applicable.

Modifier Definitions

Modifier 52 — Reduced Services

DefinitionModifier 52: Reduced Services — used when a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified healthcare professional; report by adding modifier 52 to the usual procedure number

When to useUse when the provided service is partially reduced so the basic service can still be identified by its usual procedure number with modifier 52

Reporting noteProvides a means of reporting reduced services without changing the base procedure code; see modifiers 73 and 74 for hospital outpatient situations involving anesthesia

Modifier 53 — Discontinued Procedure

DefinitionModifier 53: Discontinued Procedure — used when a surgical or diagnostic procedure is started but discontinued due to extenuating circumstances that threaten the patient’s well‑being

When not to useDo not use to report elective cancellation of a procedure prior to anesthesia induction and/or surgical preparation in the operating suite

Facility billing noteModifier 53 is not applicable for facility billing

Modifier 73 — Discontinued Prior to Anesthesia

DefinitionModifier 73: Discontinued Outpatient Hospital/ASC Procedure Prior to the Administration of Anesthesia — used when a procedure is cancelled after surgical preparation (including sedation when provided) but prior to administration of anesthesia

ScopeIntended for outpatient hospital/ASC reporting when a prepared service is cancelled; elective cancellations prior to preparation or anesthesia should not be reported

Billing applicabilityModifier 73 is not applicable for professional provider billing

Modifier 74 — Discontinued After Anesthesia

DefinitionModifier 74: Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia — used when a procedure is terminated after anesthesia has been administered or after the procedure was started (e.g., incision made, intubation, scope inserted)

When to useReport when the procedure was started or anesthesia administered and then terminated due to extenuating circumstances that threaten the patient’s well‑being

ReimbursementReimbursement for services billed with Modifier 74 is 100% of the applicable fee schedule or contracted/negotiated rate