CurrentMolina HealthcarePolicy N/A

Discontinued Procedure reimbursement (Modifier 53)

Governs Molina Healthcare reimbursement for surgical or diagnostic procedures that are initiated but subsequently discontinued and reported with CPT modifier 53; applies to providers submitting claims on CMS-1500 or electronic equivalents across Molina products and provider types.

Policy Summary

PayerMolina Healthcare

PolicyDiscontinued Procedure reimbursement (Modifier 53)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReport the usual procedure CPT code with Modifier 53 when a surgical or diagnostic procedure is initiated but discontinued; do not apply Modifier 53 to E/M services or planned cancellations before anesthesia/prep.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

33%standard reimbursement rate

50%FL/WA/MI rate (select codes)

KY, NY, AZstates exempt/non‑recognizing

CMS 1500claim form

Modifier 53modifier

Policy Summary

PayerMolina Healthcare

PolicyDiscontinued Procedure reimbursement (Modifier 53)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

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.

Coverage Criteria for Discontinued Procedures (Modifier 53)

Coverage criteria for Discontinued Procedures (Modifier 53)

Reimbursement is allowed with conditions; certain services and state Medicaid programs have exceptions.

Covered when ALL of the following are met:

ALL of the following

Procedure was initiated and subsequently discontinued by the physician or other healthcare professional — report the usual procedure code with Modifier 53 (Discontinued Procedure).
Modifier 53 is applied only to surgical or medical diagnostic procedure codes; do not apply to evaluation and management (E/M) services.
Do not apply Modifier 53 for planned cancellations that occur before anesthesia induction and/or surgical preparation in the operating suite.
Do not apply Modifier 53 when a laparoscopic or endoscopic procedure is converted to an open procedure or when the procedure is converted to a more extensive procedure; bill the appropriate code for the performed procedure instead.

ALL of the following

When a specific code exists that represents the portion of the intended procedure that was completed, Modifier 53 is not appropriate — bill the code representing the completed portion instead.
Providers must follow industry-standard coding practices and document clinical rationale for the discontinuation; improper billing may result in claim denial or recovery.

Operational: Multiple-procedure reductions and any applicable state-specific rules or exclusions must be applied when adjudicating claims.

Modifier and Reimbursement Coding Guidance

Modifier guidanceModifierCovered

Modifier 53

Discontinued Procedure modifier — apply to surgical or diagnostic procedure codes when procedure is initiated but discontinued

Reimbursement percentage for Modifier 53

Standard reimbursement33% of the Allowable Amount for the primary unmodified procedure; multiple-procedure reductions still apply.

Florida (FL)Medicaid reimburses Modifier 53 at 50%.

Washington (WA)Medicaid reimburses Modifier 53 at 50%.

Michigan (MI)Medicaid reimburses Modifier 53 at 50% with specific code exclusions (G0105-53, G0121-53, 44388-53, 45378-53 are excluded).

Kentucky (KY) and Arizona (AZ)Exempt from the Discontinued Procedure Policy; Modifier 53 is not reimbursable under those state programs.

New York (NY)NY Medicaid does not recognize Modifier 53.

Billing and Prior Authorization Guidance

Billing Rule

Submit usual CPT with Modifier 53; follow exclusions and reimbursement rules

Report the usual procedure CPT code with Modifier 53 when a surgical or diagnostic procedure is initiated but subsequently discontinued. Do not apply Modifier 53 to evaluation and management (E/M) services, planned cancellations before anesthesia induction/surgical preparation, or when a laparoscopic/endoscopic procedure is converted to an open or more extensive procedure. Molina’s standard reimbursement for procedures reported with Modifier 53 is 33% of the Allowable Amount for the primary unmodified procedure (multiple-procedure reductions still apply).

Use the usual procedure code plus Modifier 53 to indicate the procedure was initiated but discontinued.
Do not use Modifier 53 for E/M services, cancellations prior to anesthesia/prep, or conversions to open/more extensive procedures.
Standard reimbursement: 33% of the Allowable Amount for the primary unmodified procedure; multiple-procedure reductions still apply.

Definitions

CMS

DefinitionThe Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services that administers the Medicare program and partners with state governments to administer Medicaid, CHIP, and health insurance portability standards.

Allowable Amount

DefinitionAllowable Amount.

Discontinued Procedure (Modifier 53)

DefinitionA Discontinued Procedure is a surgical or diagnostic procedure that was initiated but subsequently discontinued; it should be reported using the usual procedure code with addition of Modifier 53 when appropriate.

Reporting ruleReport the usual procedure CPT code with Modifier 53 to indicate the procedure was initiated but not completed; do not apply Modifier 53 when a portion of the intended procedure has been completed and a specific code represents that completed portion.

Application limitsModifier 53 should be applied only to surgical or medical diagnostic codes and not to evaluation and management (E/M) services, planned cancellations before anesthesia/surgical prep, or when a procedure is converted to an open or more extensive procedure.