CurrentUnitedHealthcarePolicy 2025R9033A

Use and reimbursement of modifiers 52, 53, 73, and 74

Defines UnitedHealthcare Medicare Advantage reimbursement rules for reporting reduced or discontinued procedures on CMS 1500 and UB04 (UB04/CMS 1450) claims and who is affected (providers billing Medicare Advantage plans).

Policy Summary

PayerUnitedHealthcare

PolicyUse and reimbursement of modifiers 52, 53, 73, and 74

Policy CodePolicy 2025R9033A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit accurate claims using proper codes and modifiers on CMS 1500 or UB04 forms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50%Modifier 52 reimbursement

50%Modifier 53 (professional)

50%Modifier 73 (facility)

100%Modifier 74 (facility)

UB04/CMS1500Claim forms

Reimbursement Rules for Reduced and Discontinued Procedures

Policy Summary

PayerUnitedHealthcare

PolicyUse and reimbursement of modifiers 52, 53, 73, and 74

Policy CodePolicy 2025R9033A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit accurate claims using proper codes and modifiers on CMS 1500 or UB04 forms.

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.

Reimbursement criteria for reduced and discontinued procedure modifiers

UnitedHealthcare Medicare Advantage reimbursement rules for reduced or discontinued procedures:

Covered when the claim is submitted with an appropriate reduced or discontinued procedure modifier on a CMS 1500 or UB04 (UB04/CMS 1450) form.

ALL of the following

Modifier 52 is reimbursed at 50% of the Allowable Amount for the unmodified procedure.
Modifier 52 should not be used to report elective cancellation of a procedure before anesthesia induction, IV conscious sedation, or surgical preparation in the operating suite.
Modifier 52 should not be used with evaluation and management (E/M) services.

ALL of the following

Modifier 53 indicates the physician elected to terminate a surgical or diagnostic procedure due to extenuating circumstances that threatened the well‑being of the patient.
Modifier 53 is reimbursed at 50% of the Allowable Amount for the unmodified procedure.
Modifier 53 is not applicable for facility billing and is not valid when billed with E/M or time‑based codes.
Do not use Modifier 53 if a portion of the intended procedure was completed and a code exists representing the completed portion.

ALL of the following

ONE of
- Modifier 73: append when the procedure was discontinued prior to administration of anesthesia; reimbursed at 50% of the Allowable Amount for the unmodified procedure.
- Modifier 74: append when the procedure was discontinued after administration of anesthesia; reimbursed at 100% of the Allowable Amount for the unmodified procedure.
Modifiers 73 and 74 are only used to indicate discontinued procedures for which anesthesia is planned or provided and are not applicable in a professional setting.

ALL of the following

Allowable Amount is the dollar amount eligible for reimbursement (contracted rate, reasonable charge, or billed charges as applicable).

ALL of the following

Policy applies to services billed on UB04 (CMS 1450) and CMS 1500 forms.
UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; follow applicable plan authorization rules separately.

Modifiers and Reimbursement Percentages

Modifiers for reduced/discontinued proceduresModifier

Modifier 52	Reduced Services — indicates partial reduction or discontinuation of a service; used to report reduced services without disturbing the identification of the basic service; not appropriate when a code exists for the completed portion, not used for elective cancellation before anesthesia induction/IV conscious sedation/surgical preparation, and should not be used with E/M services.
Modifier 53	Discontinued Procedure — professional claims when the physician elected to terminate a surgical or diagnostic procedure due to extenuating circumstances that threatened the patient’s well‑being; not applicable for facility billing and not valid when billed with E/M or time‑based codes.
Modifier 73	Discontinued outpatient hospital/ASC procedure prior to administration of anesthesia — facility setting only; reimbursed at 50% of the Allowable Amount for the unmodified procedure.
Modifier 74	Discontinued outpatient hospital/ASC procedure after administration of anesthesia — facility setting only; reimbursed at 100% of the Allowable Amount for the unmodified procedure.

Reimbursement percentage thresholds

Modifier 52Reimbursed at 50% of the Allowable Amount for the unmodified procedure; not used for elective cancellation before anesthesia or with E/M services.

Modifier 53 (professional)Reimbursed at 50% of the Allowable Amount for the unmodified procedure; used when physician terminates a procedure due to extenuating circumstances; not valid for facility billing or with E/M/time-based codes.

Modifier 73 (facility)Reimbursed at 50% of the Allowable Amount when the procedure is discontinued prior to administration of anesthesia.

Modifier 74 (facility)Reimbursed at 100% of the Allowable Amount when the procedure is discontinued after administration of anesthesia.

Claims Submission and Provider Responsibilities

Documentation Required

Claims submission responsibility

You are responsible for submission of accurate claims using the proper procedure codes and applicable modifiers on CMS 1500 or UB04 (CMS 1450) claim forms so UnitedHealthcare can reimburse based on the codes that correctly describe the services provided.

Use CPT, CMS, or other coding guidelines referenced by the policy when selecting codes and modifiers.
Ensure modifiers for reduced or discontinued procedures (Modifiers 52, 53, 73, 74) are appended per the policy guidance to professional or facility claims as appropriate.

Key Terms and Definitions

Reduced Services (Modifier 52)

DefinitionModifier 52 (Reduced Services) identifies a service partially reduced or eliminated at the discretion of the physician and is appended to the usual procedure number.

Appropriate useUsed to indicate partial reduction or discontinuation for services that do not require anesthesia (e.g., radiology); not appropriate when a code exists for the completed portion.

Not for E/MModifier 52 should not be used with evaluation and management (E/M) services.

Discontinued Procedure (Modifiers 53, 73, 74)

Modifier 53 (professional)Indicates the physician elected to terminate a surgical or diagnostic procedure due to extenuating circumstances threatening patient well-being; reported on professional claims only; reimbursed at 50% of the Allowable Amount.

Modifier 73 (facility)Used on facility claims when a procedure is discontinued prior to administration of anesthesia; reimbursed at 50% of the Allowable Amount.

Modifier 74 (facility)Used on facility claims when a procedure is discontinued after administration of anesthesia; reimbursed at 100% of the Allowable Amount.

LimitationsModifier 53 is not applicable for facility billing and is not valid when billed with E/M or time-based codes; Modifiers 73/74 apply only when anesthesia is planned or provided.

Allowable Amount

Allowable Amount — definitionThe 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, whichever is applicable).

Determination for percent/discount contractsFor percent of charge or discount contracts, the Allowable Amount is determined as the billed amount less the discount.

Role in reimbursementReimbursement percentages for Modifiers 52, 53, 73, and 74 are applied to the Allowable Amount for the unmodified procedure as specified by this policy.