CurrentUnitedHealthcarePolicy 2025R0110B

Discontinued Procedure reporting (Modifier 53) on CMS-1500 claims

Policy Summary

PayerUnitedHealthcare

PolicyDiscontinued Procedure reporting (Modifier 53) on CMS-1500 claims

Policy CodePolicy 2025R0110B

Change TypeClarified (state exceptions updated)

Effective Date

Next Review Date

Key ActionAppend Modifier 53 only when a procedure was started but discontinued and submit claims with the correct codes and modifiers to ensure appropriate reimbursement.

SourceLink

POLICY UPDATE CHANGES

State exceptions updated — Idaho added to the State Exceptions list.

33%standard reimbursement for discontinued procedures (Modifier 53)

50%Florida Medicaid reimbursement for Modifier 53 (state exception)

When to Report Modifier 53 (Discontinued Procedure)

When Modifier 53 is appropriate

Use Modifier 53 to report procedures that were started but discontinued at the physician's direction under certain circumstances; do not use for listed exclusions.

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ALL of the following

Procedure was started but terminated at physician or qualified health care professional's direction due to circumstances (e.g., serious risk to patient's well-being) making continuation inappropriate.
Report the usual (full) procedure code with Modifier 53 appended to indicate discontinued procedure.
Multiple procedure reductions still apply when Modifier 53 is reported.

ANY of the following

Modifier 53 should be used with surgical codes or medical diagnostic codes (per CMS/CPT guidance).
Modifier 53 should NOT be used with Evaluation & Management (E/M) services.
Modifier 53 should NOT be used for elective cancellations prior to anesthesia induction and/or surgical preparation in the operating suite.
Modifier 53 should NOT be used when a laparoscopic or endoscopic procedure is converted to an open procedure or changed/converted to a more extensive procedure (use code representing the completed portion instead).

Billing, Documentation, and State Exceptions

Billing Rule

Reimbursement percentage for discontinued procedures

UnitedHealthcare Community Plan's standard reimbursement for procedures reported with Modifier 53 is 33% of the Allowable Amount for the primary unmodified procedure. Multiple procedure reductions will still apply.

Billing Rule

State-specific reimbursement exceptions

State rules may override the standard 33% reimbursement: Florida Medicaid reimburses Modifier 53 at 50%; New York Medicaid does not recognize Modifier 53; Washington Medicaid is exempt from this Discontinued Procedure Policy. Idaho was added to the State Exceptions list.

Florida: FL Medicaid reimbursement for modifier 53 is 50%
New York: NY Medicaid does not recognize modifier 53
Washington: WA Medicaid is exempt from the Discontinued Procedure Policy
Idaho: added to State Exceptions

Documentation Required

Accurate claims submission

Providers are responsible for submitting accurate claims and must append the correct code(s) and modifier(s) that describe services provided; use Modifier 53 only when clinically appropriate and per CPT/CMS guidance.

Policy Scope and Summary

Defines UnitedHealthcare Community Plan reimbursement rules for procedures started but discontinued (reported with CPT modifier 53) on CMS-1500 claims and, when specified, UB04. This reimbursement policy applies to professional claims submitted on the CMS-1500 and, when specified, to UB04 claims and is intended to ensure reimbursement is based on the code(s) that correctly describe the services provided.

Use Modifier 53 to report a Discontinued Procedure — a surgical or diagnostic procedure that was started but terminated at the physician's or other qualified health care professional's direction (for example, due to a serious risk to the patient's well-being). Report the usual (full) procedure code with Modifier 53 appended; do not use Modifier 53 when a code exists that represents the completed portion of the intended procedure.

UnitedHealthcare Community Plan'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. State-specific reimbursement rules may override the standard rate — for example, Florida Medicaid reimburses Modifier 53 at 50%, New York Medicaid does not recognize Modifier 53, and Washington Medicaid is exempt from this Discontinued Procedure Policy (Idaho has also been added to the state exceptions list).

Providers are responsible for submitting accurate claims and must append the correct code(s) and modifier(s) that describe services provided. Modifier 53 should be used only with surgical or medical diagnostic codes per CMS/CPT guidance and should not be used with Evaluation & Management (E/M) services, for elective cancellations prior to anesthesia induction and/or surgical preparation in the operating suite, or when a laparoscopic/endoscopic procedure is converted to an open or more extensive procedure (in those cases report the code for the completed portion).

Policy Summary

PayerUnitedHealthcare

PolicyDiscontinued Procedure reporting (Modifier 53) on CMS-1500 claims

Policy CodePolicy 2025R0110B

Change TypeClarified (state exceptions updated)

Effective Date

Next Review Date

Key ActionAppend Modifier 53 only when a procedure was started but discontinued and submit claims with the correct codes and modifiers to ensure appropriate reimbursement.

SourceLink

On This Page

53	Discontinued Procedure — appended to the usual procedure code when the procedure was started but discontinued
52	Reduced Services — see Reduced Services (Modifier 52) policy for partially reduced or eliminated procedures

OpenPayer

Discontinued Procedure reporting (Modifier 53) on CMS-1500 claims

When to Report Modifier 53 (Discontinued Procedure)

Codes and Modifiers

Billing, Documentation, and State Exceptions

Policy Scope and Summary

Defined Terms

Policy Update Changes

Discontinued Procedure reporting (Modifier 53) on CMS-1500 claims

When to Report Modifier 53 (Discontinued Procedure)

Codes and Modifiers

Billing, Documentation, and State Exceptions

Policy Scope and Summary

Defined Terms

Policies to Read With This Policy

Policy Update Changes