CurrentMolina HealthcarePolicy N/A

Discontinued Procedure (Modifier 53) Reimbursement

Defines Molina Healthcare's reimbursement policy for procedures discontinued after initiation reported with CPT Modifier 53, applicable to providers submitting CMS 1500 or electronic equivalents across Molina products.

Policy Summary

PayerMolina Healthcare

PolicyDiscontinued Procedure (Modifier 53) Reimbursement

Policy CodePolicy N/A

Change TypeTemplate and state exception updates

Effective DateN/A

Next Review DateN/A

Key ActionReport the usual procedure code with Modifier 53 when a procedure is initiated but discontinued; do not use Modifier 53 for E/M services, planned pre-procedure cancellations, or conversions to a more extensive/open procedure.

SourceLink

POLICY UPDATE CHANGES

Updated State Exceptions.

Updated Template.

33%Standard reimbursement for discontinued procedures with Modifier 53

50%State-specific reimbursement rate (examples)

KY, NY, AZStates with exemption or non-reimbursement

09/01/2023Initial creation date

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.

Discontinued Procedure Coverage Criteria

Reimbursement applies when ALL of the following are met:

ALL of the following

ALL of the following
- ALL of the following
  - Procedure was initiated and subsequently discontinued on the direction of the physician or other healthcare professional and is reported using the usual procedure code plus Modifier 53.
ALL of the following
- Modifier 53 is applied only to surgical or medical diagnostic procedure codes; it is not appropriate for evaluation and management (E/M) services.
ALL of the following
- Do not apply Modifier 53 when any of the following apply:
  - Planned cancellation of a procedure before anesthesia induction and/or surgical preparation in the operating suite.
  - A laparoscopic or endoscopic procedure is converted to an open procedure or the procedure is changed/converted to a more extensive procedure; use the appropriate alternative procedure code instead of Modifier 53.
ALL of the following
- Standard reimbursement is 33% of the Allowable Amount for the unmodified primary procedure; multiple procedure reductions still apply.
- State exceptions (override standard reimbursement)
  - Florida (FL): Medicaid reimbursement for Modifier 53 is 50%.
  - Washington (WA): Medicaid reimbursement for Modifier 53 is 50%.
  - Michigan (MI): Medicaid reimburses 50% for Modifier 53 with listed code exceptions (G0105-53, G0121-53, 44388-53, 45378-53 excluded).
  - Kentucky (KY): KY Medicaid is exempt from the Discontinued Procedure Policy; modifier 53 is not reimbursable.

ref": "b0_0

title": "Discontinued Procedure Coverage Criteria"

Coding and Reimbursement Details

Discontinued Procedure CodingModifierCovered

Modifier 53

Discontinued Procedure modifier applied to the usual procedure code when the procedure is initiated but subsequently discontinued.

Reimbursement percentage — Discontinued Procedure (Modifier 53)

Standard reimbursement33% of the Allowable Amount for the primary unmodified procedure (multiple procedure reductions still apply)

Florida (FL)Reimburses Modifier 53 at 50%

Washington (WA)Reimburses Modifier 53 at 50%

Michigan (MI)Reimburses Modifier 53 at 50% with listed code exceptions (excludes G0105-53, G0121-53, 44388-53, 45378-53)

Kentucky (KY)Exempt from the Discontinued Procedure Policy; Modifier 53 is not reimbursable

New York (NY) and Arizona (AZ)NY does not recognize Modifier 53 (not reimbursable); AZ is exempt from the Discontinued Procedure Policy

Provider Reporting Requirements

Billing Rule

Report usual procedure code with Modifier 53 when procedure initiated but discontinued

Report the usual procedure code with Modifier 53 (Discontinued Procedure) when a surgical or diagnostic procedure is initiated but subsequently discontinued on the direction of the physician. Modifier 53 indicates the procedure was initiated but discontinued and must be applied only to surgical or medical diagnostic codes.

Do not use Modifier 53 for Evaluation and Management (E/M) services.
Do not use Modifier 53 for planned cancellation before anesthesia induction and/or surgical preparation in the operating suite.
Do not use Modifier 53 when a laparoscopic or endoscopic procedure is converted to an open procedure or when the procedure is changed to a more extensive procedure; report the appropriate code for the completed work instead.
When a portion of the intended procedure has been completed and a corresponding code exists for that completed portion, do not apply Modifier 53 — report the code that represents the completed segment.

Key Definitions

Discontinued Procedure — definition

DefinitionA surgical or diagnostic procedure that was initiated but halted on the direction of the physician or other healthcare professional and reported using the usual procedure code plus Modifier 53 to indicate discontinuation.

ReportingIndicate the Discontinued Procedure by appending Modifier 53 to the usual procedure code; do not use Modifier 53 when a portion of the intended procedure has been completed and a specific code exists for that completed portion.

Appropriate useApply Modifier 53 exclusively to surgical or medical diagnostic procedure codes; not appropriate for E/M services, planned pre-anesthesia cancellations, or conversions to open/more extensive procedures.

CMS — definition

AcronymCMS = Centers for Medicare & Medicaid Services

RoleFederal agency within the U.S. Department of Health and Human Services that administers Medicare and partners with states to administer Medicaid and CHIP.

RelevanceCMS guidance and CPT coding standards are referenced for appropriate use of Modifier 53 and reimbursement practices.

Allowable Amount — definition

TermAllowable Amount

ContextUsed as the basis for calculating Molina Healthcare's reimbursement for Discontinued Procedures (standard reimbursement is 33% of the Allowable Amount for the primary unmodified procedure).

InteractionMultiple procedure reductions and state-specific exceptions may affect the final reimbursable amount calculated from the Allowable Amount.