CurrentColorado Rocky Mountain Health PlansPolicy N/A

Outpatient facility modifier reimbursement (52, 53, 73, 74)

Defines how UnitedHealthcare Community Plan reimburses outpatient facility claims billed on UB04 (or electronic equivalent) when modifiers 52, 53, 73, and 74 are appended; applies to UnitedHealthcare Community Plan Medicaid products and all network and non-network outpatient facility claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOutpatient facility modifier reimbursement (52, 53, 73, 74)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit modifier 53 on facility UB04 claims; modifiers 52 and 73 will trigger a 50% reduction to the allowable amount; modifier 74 may be submitted for informational purposes without reduction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%reduction applied when modifier 52 is present

50%reduction applied when modifier 73 is present

denialfacility claim lines with modifier 53

informationalmodifier 74 on facility claim lines

UB04

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Modifier-specific reimbursement rules

Modifier-specific coverage rules

Reimbursement and claim adjudication rules for specific modifiers on outpatient facility UB04 claims:

ALL of the following

ALL of the following
- If modifier 52 is present on an outpatient facility claim line, reduce the allowed (allowable) amount by 50% (subject to state exceptions).50%
  State exceptions may alter the reduction (examples: Arizona, Minnesota exempt; Idaho reimburses at 75%; see state-specific guidance).
ALL of the following
- If modifier 73 is present on an outpatient facility claim line, reduce the allowed (allowable) amount by 50%.50%
ALL of the following
- Modifier 53 is not appropriate on facility claims; when submitted the facility claim line will be denied. Provider may resubmit with an appropriate modifier if applicable.
ALL of the following
- Modifier 74 is informational on facility claims and will not result in a reimbursement reduction; it may be submitted for outpatient hospital reporting when appropriate.

Modifiers and allowed amount adjustments

Outpatient facility modifiers addressedModifier

52	Reduced services — allowed amount reduced by 50% on facility claims
73	Discontinued prior to anesthesia — allowed amount reduced by 50% on facility claims
53	Discontinued — not appropriate on facility claims; will be denied
74	Discontinued after anesthesia — informational modifier; no reduction

State exceptions (examples)mixed

Arizona	Exempt from policy
Idaho	Idaho reimbursement for modifier 52 is 75%
Minnesota	Exempt from policy
Nebraska	Exempt from policy
Tennessee	Exempt from policy

Allowed amount reduction — modifiers 52 and 73

Allowed amount reductionWhen modifier 52 or modifier 73 is present on an outpatient facility claim line the allowed (allowable) amount will be reduced by 50% (subject to state exceptions).

State exceptionsCertain states are exempt or have alternate rates (examples: Arizona, Minnesota, Nebraska exempt; Idaho = 75% for modifier 52; Tennessee exempt).

Applies to UB04 facility claimsThis reduction policy governs outpatient facility claim lines billed on UB04 (or electronic equivalent).

Billing and submission actions for facility claims

Billing Rule

Modifier billing actions for outpatient facility claims (UB04)

Do not submit modifier 53 on outpatient facility (UB04) claim lines; if submitted the claim line will be denied and the provider may resubmit with an appropriate modifier if applicable. Modifiers 52 and 73, when appended to an outpatient facility claim line, will reduce the allowed/allowable amount by 50% (subject to state exceptions). Modifier 74 may be submitted on a facility claim line for informational purposes and will not result in a reimbursement reduction.

Modifier 53: not appropriate on facility claims — claim line will be denied; provider may resubmit with an appropriate modifier if applicable. (See Q&A confirmation.)
Modifiers 52 and 73: each triggers a 50% reduction to the allowed/allowable amount on outpatient facility claim lines (state exceptions may apply).
Modifier 74: informational on facility claims; no reduction in reimbursement when appended.

Key terms and definitions

Allowable Amount

Allowable Amount — definitionDefined as the dollar amount eligible for reimbursement to the physician or Other Qualified Health Care Professional on the claim (examples: contracted rate, reasonable charge, or billed charges as applicable).

Determination examplesFor percent-of-charge or discount contracts, the Allowable Amount is the billed amount less the discount; other contract terms (contracted rate, reasonable charge) may apply.

Use in this policyAllowable Amount is the base against which reductions (for modifiers 52 and 73) are applied and is the reference for reimbursement determinations on facility UB04 claim lines.

Modifier (52 / 53 / 73 / 74) — definitions and policy actions

Modifier 52Reduced services — when appended to an outpatient facility claim line, the allowed/allowable amount will be reduced by 50%.

Modifier 73