CurrentEmblemHealthPolicy RPC2O230042

Discontinued Procedures/Reduced Services Modifiers 52, 53, 73 & 74 (Commercial)

Billing and reimbursement guidelines for reporting discontinued or reduced surgical and diagnostic procedures using CPT modifiers 52, 53, 73 and 74 for EmblemHealth commercial facility and professional claims.

Policy Summary

PayerEmblemHealth

PolicyDiscontinued Procedures/Reduced Services Modifiers 52, 53, 73 & 74 (Commercial)

Policy CodePolicy RPC2O230042

Change TypeClarified and reformatted (non-material)

Effective DateJan 1, 2021

Next Review Date

Key ActionMaintain operative/procedure reports and supporting documentation and provide them upon request.

SourceLink

POLICY UPDATE CHANGES

Added additional clarification regarding appropriate use of modifiers 52 & 53.

Reformatted and reorganized policy and transferred content to new template with new Reimbursement Policy Number.

Transferred policy content to individual company-branded template; no changes to policy title or number.

4modifiers addressed (52, 53, 73, 74)

50%facility reimbursement with modifier 52

1max discontinued per encounter

usualmodifier 74 facility reimbursement

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.

Coverage Criteria for Discontinued and Reduced Procedures

Facility and professional billing criteria for discontinued/reduced procedures

Conditions under which modifiers may be reported and how reimbursement is handled.

Facility and professional billing for discontinued or reduced procedures follow specific modifier rules and reimbursement provisions; report and reimburse only as specified below.

ALL of the following

Use modifier 73 to report a procedure discontinued prior to administration of anesthesia when the patient was prepared and taken to the procedure room.
Modifier 73 is valid on a maximum of one procedure code per patient encounter.
Do not combine modifier 73 with modifier 50 (bilateral) on the same procedure code; when a bilateral procedure is discontinued before either side is completed, report only a unilateral procedure with modifier 73.

ALL of the following

Use modifier 74 to report a procedure discontinued after anesthesia is induced or after the procedure is initiated.
Modifier 74 may not be used if anesthesia was not planned for the procedure; the patient must have been prepared for the procedure and taken to the room to report modifier 74.
Procedures reported with modifier 74 will be reimbursed at the usual applicable facility fee schedule rate; member cost-sharing applies.

ALL of the following

Use modifier 52 to report reduced services when procedures (for which anesthesia is not planned) are terminated, discontinued, or otherwise reduced after the patient is prepared and taken to the procedure room.
A maximum of one terminated or discontinued procedure may be reported with modifier 52 per encounter.
Do not submit modifier 52 to report an elective cancellation before anesthesia induction or surgical preparation; do not submit modifier 52 if the procedure is discontinued after administration of anesthesia.
When multiple procedures are planned and none are completed, report only the first planned and discontinued procedure with modifier 52; other planned but not started procedures are not reported.
When a bilateral procedure without anesthesia is planned and discontinued after arrival in the procedure room, only a unilateral (first) side may be reported with modifier 52; do not report modifier 50 with modifier 52 on the same procedure code.

ALL of the following

Use modifier 53 for physician/professional discontinued procedures only; it is not approved for use by outpatient hospital services or ASCs.
Modifier 53 is considered valid on a maximum of one procedure code per date of service.
Do not submit modifier 53 to report an elective cancellation prior to anesthesia induction or when a laparoscopic/endoscopic procedure is converted to open.
Do not report modifier 50 and modifier 53 together on the same procedure code; when a bilateral procedure is planned and discontinued before either side is completed, only a unilateral procedure code may be reported with modifier 53.

ALL of the following

When multiple procedures are planned and one or more are completed, report the completed procedures as usual; planned procedures not started are not reported.
If none of the planned procedures are completed, report only the first planned procedure as discontinued with the applicable modifier (52 or 53 as appropriate); other planned procedures not started are not reported.

Documentation and modifier usage requirements

Billing must be supported by medical record documentation; modifiers 52, 53, 73, and 74 are addressed in policy and require appropriate documentation.

The medical record must document that the procedure was started.

The medical record must document the reason the procedure was discontinued.

The medical record must document the percentage of the procedure that was performed.

Supporting documentation (operative/procedure report and related records) must be maintained and made available for review upon request; documentation should specify services actually performed, reasons for termination, supplies provided or not provided, time spent in stages, and the planned CPT/HCPCS code.

The policy provides guidance on appropriate use of modifiers 52 and 53 and discontinued procedure modifiers 73 and 74; ensure modifier selection aligns with documentation and the circumstances of discontinuation (e.g., anesthesia planned or not, timing of discontinuation).

Coding and Modifiers

Modifiers for discontinued or reduced proceduresModifier

73	Discontinued outpatient hospital/ASC procedure prior to administration of anesthesia
74	Discontinued outpatient hospital/ASC procedure after administration of anesthesia or after procedure started
52	Reduced services — service partially reduced or eliminated (physician or hospital outpatient reporting)
53	Discontinued procedure — physician/professional services only

Modifiers addressedModifier

52	Reduced services modifier
53	Discontinued procedure modifier
73	Discontinued outpatient hospital/ambulatory surgery prior to anesthesia
74	Discontinued outpatient hospital/ambulatory surgery after anesthesia

Maximum reportable discontinued procedures

Maximum reportable discontinued/terminated procedures per encounter1 per encounter (maximum of one procedure code may be reported with modifier 52, 53 or 73).

Multiple planned procedures — completed vs discontinuedIf one or more planned procedures are completed, report completed procedures as usual; planned but unstarted procedures are not reported.

Multiple planned procedures — none completedIf none of the planned procedures are completed, report only the first planned procedure as discontinued with the applicable modifier.

Modifier 52 — Facility reimbursement

Facility reimbursement when modifier 52 is used50% of the usual applicable facility fee schedule for the facility fee.

Member cost-sharingMember copayment, coinsurance, and deductible provisions apply to reimbursements for procedures reported with modifier 52.

Use limitationsA maximum of one terminated or discontinued procedure may be reported with modifier 52 per encounter.

Provider Actions and Documentation Obligations

Documentation Required

Documentation submission on request

Keep operative/procedure reports and related documentation on file and provide them upon request. The operative report should specify services actually performed; reason for termination/discontinuation; supplies actually provided and supplies that would have been provided if the procedure had not been terminated; services not performed that would have been performed; time actually spent in each stage (pre-operative, operative, post-operative); HCPCS/CPT code for the procedure had it been completed; and estimated time that would have been spent in each stage if the surgery had not been terminated.

Ensure documentation is retained by the ASC/hospital and is available for claim review upon request.
Operative/procedure report must detail the percent (or proportion) of the procedure performed when a procedure is discontinued or reduced.

Denial Risk

Coding compliance and audit risk

We follow industry coding and editing standards (eg, AMA CPT guidelines, specialty organization guidance, CMS policies including NCCI and MUE) and use industry-standard claims editing software to make coding decisions. Upon request, we will provide an explanation of how specific coding issues are handled. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim denial and/or recoupment.

May request explanation of how specific coding issues are handled.
Noncompliance with coding/billing guidelines can lead to denial or repayment recovery.

Documentation Required

Documentation requirement for discontinued/reduced procedures

Maintain medical record documentation that the procedure was started, why it was discontinued, and the percentage of the procedure that was performed. This supporting documentation must be available for review upon request and should be coordinated with the surgeon/physician to ensure it includes the required details.

When reporting modifiers 52, 53, 73, or 74, keep documentation on file and available for claim review.
Documentation should include reason for termination, services actually performed, supplies provided, and percent completed.

Definitions and Modifier Meanings

Discontinued Procedure — definition

DefinitionA surgical or diagnostic procedure that was less than usually required for the procedure as defined in the Current Procedural Terminology (CPT).

ScopeApplies to discontinued, cancelled, terminated, or reduced procedures reported with modifiers 52, 53, 73 or 74.

Reporting contextThis policy describes billing instructions and guidelines when billing for a discontinued procedure using CPT modifiers 52, 53, 73 or 74.

Modifier 73

Modifier code73

DefinitionDiscontinued outpatient hospital/ASC procedure prior to administration of anesthesia — report when the intended service was prepared for (including sedation and being taken to the room) but cancelled prior to anesthesia administration.

Reporting limitValid on a maximum of one procedure code for the patient encounter; do not combine with modifier 50 on the same procedure code.

Modifier 74

Modifier code74

DefinitionDiscontinued outpatient hospital/ASC procedure after administration of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) — report the procedure started but terminated with modifier 74.

Reimbursement noteProcedures discontinued after anesthesia are reported with modifier 74 as described in facility billing guidelines.

Modifier 52

Modifier code52

DefinitionReduced Services — service or procedure partially reduced or eliminated at the physician's discretion; identifies that the basic service was performed but not all aspects were performed.

Reporting noteUsed to identify reduced services without changing the basic procedure identification; not for elective cancellations before anesthesia induction/surgical preparation.

Modifier 53

Modifier code53

DefinitionDiscontinued Procedure — physician and professional services only; indicates the physician elected to terminate a surgical or diagnostic procedure after it was started.

Use limitationNot approved for use by outpatient hospital services or ASCs (such claims will be denied); valid on a maximum of one procedure code per date of service.

Documentation requirements for discontinued/reduced procedures

Required documentation elementsMedical record must document that the procedure was started, the reason it was discontinued, and the percentage of the procedure that was performed.

AvailabilitySupporting documentation must be available for review upon request.

Content guidanceDocumentation should support the reported modifier and services actually performed (e.g., stages, supplies, planned CPT/HCPCS code).

OpenPayer

Discontinued Procedures/Reduced Services Modifiers 52, 53, 73 & 74 (Commercial)

Coverage Criteria for Discontinued and Reduced Procedures

Coding and Modifiers

Provider Actions and Documentation Obligations

Definitions and Modifier Meanings

Policy Revision History