Modifier 73 and 74, Usage and Guidelines

Modifier -73, Discontinued procedure prior to the administration of anesthesia; Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia

Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancela surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier 73.

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

Modifier -73 is used when a physician cancels a surgical procedure due to the onset of medical complications subsequent to the patient’s preparation, but prior to the administration of anesthesia.  Payment will be at 50% of the maximum allowable fee for the primary procedure only.  Multiple and bilateral procedure pricing will not apply.

Modifier -74, Discontinued procedure after administration of anesthesia - Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after  aministration of anesthesia
Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier 74.

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

Modifier -74 is used when a physician terminates a surgical procedure due to the onset of medical complications after the administration of anesthesia or after the procedure was started.  Payment will be at 85% of the maximum allowable fee.  Multiple and bilateral procedure pricing may apply to this if appropriate to the circumstances.

Use of Modifiers -52, -73, and -74 for Reduced or Discontinued Services - Hospital Outpatient facility billing

Policy: This manual revision clarifies use of modifiers -52, -73 and -74. These modifiers are used to report procedures that are discontinued by the physician due to unforeseen circumstances. For billing under the OPPS, modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. For surgeries and certain diagnostic procedures requiring anesthesia (including colonoscopies), the hospital may receive 50 percent of the OPPS payment amount for cases in which the procedure is discontinued after the beneficiary was prepared for the procedure and taken to the room where the procedure was to be performed. If the procedure is discontinued after the beneficiary has received anesthesia or after the procedure was started (e.g., scope inserted, intubation started, incision made) the hospital may receive the full OPPS payment amount for the discontinued procedure. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, and general anesthesia. This manual revision also clarifies that discontinued radiology procedures that do not require anesthesia may not be reported using modifiers -73 and -74.
Modifiers -73, and -74 apply only to certain diagnostic and surgical procedures that require anesthesia.

Medicare Guidelines to Use modifier 72 and Modifier 73 - Use of Modifiers for Discontinued Services 

Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers.  Modifier -73 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well being of the patient after the patient had been prepared for the procedure (including procedural pre-medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.

Modifier -74 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well being of the patient. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, and general anesthesia. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion. Prior to January 1, 1999, modifier -53 was used for reporting these discontinued services

Modifiers -73 and -74 are used to indicate discontinued surgical and certain diagnostic procedures only. They are not used to indicate discontinued radiology  procedures.


Effect on Payment

Surgical or certain diagnostic procedures that are discontinued after the patient has been prepared for the procedure and taken to the procedure room for which modifier -73 is coded, will be paid at 50 percent of the full OPPS payment amount.

Surgical or certain diagnostic procedures that are discontinued after the procedure has been initiated and/or the patient has received anesthesia for which modifier -74 is coded, will be paid at the full OPPS payment amount.

Termination Where Multiple Procedures Planned

When one or more of the procedures planned is completed, the completed procedures are reported as usual.

When one or more of the procedures planned is completed, the completed procedures are reported as usual. The other(s) that were planned, and not started, are not reported. When none of the procedures that were planned are completed, and the patient has been prepared and taken to the procedure room, the first procedure that was planned, but not completed is reported with modifier -73. If the first procedure has been started (scope inserted, intubation started, incision made, etc.) and/or the patient has received anesthesia, modifier -74 is used. The other procedures are not reported.

If the first procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed in order to report modifier -73 or -74.
Specifications:

Modifier -73 is used by outpatient facilities to specify a surgical or diagnostic same day outpatient procedure, requiring anesthesia. Certain outpatient procedures are usually covered by Aetna if they are performed on an outpatient basis. Reimbursement for these outpatient services is primarily made on a flat fee service and coded with Revenue code 490. Per coding guidelines, Modifier 73 indicates a surgery cancellation prior to anesthesia.

Reimbursement Guidelines - Aetna

1) For surgeries and certain diagnostic same day procedures requiring anesthesia (including colonoscopies), the hospital may receive fifty percent (50%) of the OPPS payment amount for cases in which the procedure is discontinued after the beneficiary was equipped for the procedure and taken to the room where the procedure was to be implemented.

2) If the procedure is withdrawn after the beneficiary has received anesthesia or after the same day procedure was started (e.g., scope inserted, intubation started, incision made) the hospital may receive the full OPPS payment amount for the discontinued procedure.

3) Providers do not use a modifier if the narrative definition of a code indicates several incidences.

4) If the patient has multiple procedures that were planned and not begun, they are not reported. When no procedure was planned or completed, and the patient was prepared and taken to the procedure room, the first procedure that was planned, but not completed is reported with modifier -73.

Codes/Condition of Coverage

Outpatient CPT Codes:
99201-99205, 99211, 99213-99215
Revenue Codes:
510, 514, 515, 517

Does Provider can Use this modifier 73 and 74 in office visite and other setup?

No , This modifier is approved for ambulatory surgery center (ASC) hospital outpatient use Services and Modifiers Not Reimbursable to Healthcare Professionals.

AMBULATORY SURGICAL CENTERS

 SERVICES PROVIDED BY HOSPITAL OUTPATIENT FACILITIES AND/OR AMBULATORY SURGICAL CENTERS: For any pathology and laboratory service(s) provided by a hospital outpatient facility and/or ambulatory surgical center, reimbursement for said service is to be limited to the maximum allowable payment contained within this section of the Fee Schedule. 

 MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the same day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On Codes. 

ADD-ON CODES: Certain codes, by the nature of their description and the maximum fee assigned, have already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes which are considered to be add-on codes, refer to the appropriate appendix found within the most recent publication of the AMA Current Procedural Terminology (CPT). 

 REPORTS: No statement of charges for services or procedures included in this section shall be considered properly rendered unless it is accompanied by a report that includes both the findings and an interpretation of such findings. 

 PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Maximum Fee column indicates that the charge for this service is to be determined "by report" because the service is too unusual or variable to be assigned a Maximum Fee. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the time, skill, and equipment necessary, etc. 

 INDICES OR RATIOS: Tests which produce an index or ratio based on mathematical calculations from two or more other results may not be billed as separate independent tests (e.g., A/G ratio, free thyroxin index). 

 UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or procedure codes usually end in "99." 

 DENIAL OF PAYMENT: Payment may be denied for procedures or services determined to be excessive or unnecessary for the management of the work-related injury or disease. 

 MODIFIERS: Procedure codes for pathology and laboratory services may be modified under certain circumstances. The circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code. Refer to Appendix A - Modifiers for a list of modifiers that may be used. 

PATHOLOGY AND LABORATORY GROUND RULES

 SEROLOGY: All serological procedures must be performed by registered pathologists or laboratories. 

 MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and material provided by the health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. The statement of charges will need to list individually any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. 

MAXIMUM FEES: The Maximum Fees specified herein apply to laboratories owned or operated by a health care provider, hospital laboratories, and commercial laboratories, but only when the services or procedures are performed by or under the responsible supervision of a health care provider. When a health care provider is hospital based and is not salaried or otherwise compensated for the services listed in this section, a separate bill can be rendered for the particular service. The charge is to be 60% of the Maximum Fee. 

The Maximum Fees specified herein include both the "professional" component and the "technical" component. Identification of a service or procedure by its five-digit code, without pertinent modifiers, indicates that the charge includes both the professional and technical components. Where the maximum fee is “0” for either the professional component or the technical component there is no designated payment allowed. 

The professional component includes the examination of the patient when indicated, performance or supervision of the procedure, interpretation and written report of the examination including procedure results (e.g., x-ray images), and consultation with the referring health care provider. To identify a charge for the professional component only, see Appendix A - Modifiers for modifier -26. Unless otherwise specified in the Schedule, the maximum allowable charge for the professional component is 60% of the listed Maximum Fee in the ATS@ column. 

Nuclear Medicine and Diagnostic Ultrasound

 ADD-ON CODES: Certain codes, by the nature of their description and the maximum fees assigned, have already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes which are considered to be add-on codes, refer to the appropriate appendix found within the most recent publication of the AMA Current Procedural Terminology (CPT). 

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25% of the cost or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. The Maximum Fees in this section do not include radiopharmaceutical or other radionuclide material costs. List the name and dosage of radiopharmaceutical material and cost. 

 INJECTION PROCEDURES: Charges for injection procedures are to include all usual pre- and post-injection care specifically related to the injection procedure, necessary local anesthesia, placement of needle or catheter, and injection of contrast media. Vascular injection procedures are listed under the Cardiovascular Subsection of the Surgery Section, procedure codes 36000-36299. Other injection procedures are listed in pertinent sections. 

PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in a maximum fee column indicates that the amount charged for this service is to be determined "by report" because the service is too unusual, or variable to be assigned a maximum fee. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the time, skill, and equipment necessary, etc. Additional items which may be helpful might include: complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care. 

 UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or procedure codes usually end in "99." 

MODIFIERS: Procedure codes for radiology services may be modified under certain circumstances. The circumstances are to be identified by the addition of a hyphen and the appropriate two digit modifier code. Refer to Appendix A - Modifiers for a list of modifiers that may be used. 

RADIOLOGY GROUND RULES

DUPLICATION OF X-RAYS: Every attempt should be made to minimize the number of x-rays taken. The attending health care provider or any other person or institution having possession of x-rays, which pertain to the patient and are deemed to be needed for diagnostic or treatment purposes, should make those x-rays available upon request. No payments shall be made for additional x-rays when recent x-rays are available, except when the charge is supported by adequate information regarding the need to perform another x-ray. 

PHOTOGRAPHIC MEDIA: The use of photographic media or imaging is not reported separately but is considered to be a component of the basic procedure and shall not merit any additional payment.

 XERORADIOGRAPHY: Imaging performed by this process shall have the same Maximum Allowable Fees as those listed for conventional x-ray procedures of the same anatomical area and views. 

 MAXIMUM FEES: The Maximum Fees contained within this fee schedule include both the "professional component” and the "technical component”. Identification of a service or procedure by its five digit code, without pertinent modifiers, indicates that the services provided include both the professional and technical components. Where the value is “0” for either the professional component or technical component there is no designated payment allowed. The professional component includes the examination of the patient when indicated, performance or supervision of the procedure, interpretation and written report of the examination including procedure results (e.g., x-ray images), and consultation with the referring health care provider. The value is shown in the “PC” column of this fee schedule. The technical component includes the charges for personnel, materials and other supplies, and space, equipment, and other facilities, but excludes the cost of radioisotopes. The value is shown in the “TC” column of this fee schedule. The total services component includes both the professional component and the technical component. The value is shown in the “TS” column of this fee schedule. Hospital outpatient facilities and ambulatory surgical centers must specify, by use of modifiers, when only the technical component or the professional component is provided. 

SERVICES PROVIDED BY A HOSPITAL OUTPATIENT FACILITY AND/OR AMBULATORY SURGICAL CENTER: For any radiology service(s) provided by a hospital outpatient facility and/or ambulatory surgical center, reimbursement for said service is to be limited to the maximum allowable payment contained within this section of the Fee Schedule. 

Surgery

10021 XXX $312.27 

10022 XXX $292.94 

10030 XXX $1,640.90 

10040 10 $211.15 

10060 10 $241.64 

10061 10 $429.74 

10080 10 $373.24 

10081 10 $565.80 

10120 10 $316.73 

10121 10 $573.98 

10140 10 $339.78 

10160 10 $271.38 

10180 10 $515.99 

11000 0 $113.76 

11001 ZZZ $44.61 

11004 0 $1,234.21 

11005 0 $1,662.47 

11006 0 $1,495.92 

11008 ZZZ $582.90 

11010 10 $1,020.08 

11011 0 $1,127.89 

11012 0 $1,490.72 

11042 0 $243.12 

11043 0 $482.53 

11044 0 $669.15 

11045 ZZZ $89.22 

11046 ZZZ $154.65 

11047 ZZZ $263.94 

11055 0 $98.89 

11056 0 $121.19 

11057 0 $136.80 

11100 0 $212.64 

11101 ZZZ $67.66 

11200 10 $182.90  

11201 ZZZ $40.15  

11300 0 $199.26 

11301 0 $245.36  

11302 0 $289.22 

11303 0 $321.19 

11604 10 $653.54

11603 10 $585.13

11602 10 $513.02

11951 0 $217.10

11601 10 $472.87 

11601 10 $472.87 

11950 0 $159.11

11600 10 $400.00

11922 ZZZ $128.63

11922 ZZZ $128.63

11471 90 $1,073.61

11921 0 $416.36

11470 90 $865.43 

11920 0 $358.37

11463 90 $1,031.98

 11901 0 $144.98

11462 90 $768.78 

11900 0 $114.50

11451 90 $1,008.19 

11772 90 $1,449.08

11450 90 $787.37 

11446 10 $818.59 

11770 10 $579.19

11444 10 $588.85 

11765 10 $346.47

11443 10 $466.17 

11442 10 $391.08 

11762 10 $591.08

11760 10 $485.51

11441 10 $349.45 

11440 10 $281.04 

11426 10 $695.17 

11755 0 $279.56

11750 10 $468.41

11752 10 $673.61

11424 10 $484.76 

11740 0 $103.35

11423 10 $420.08 

11732 ZZZ $74.35

11422 10 $364.32 

11730 0 $206.69

11421 10 $326.40 

11721 0 $93.68

11420 10 $253.53 

11720 0 $67.66

11305 0 $203.72 

11606 10 $936.81

11306 0 $250.56 

11620 10 $404.46

11307 0 $295.91

 11621 10 $475.84

11308 0 $311.53 

11622 10 $530.86

11406 10 $651.31 

11719 0 $29.00

11404 10 $450.56 

11646 10 $1,078.82

11403 10 $397.03 

11644 10 $823.80

11402 10 $342.75 

11643 10 $667.66

11401 10 $307.81 

11642 10 $562.09

11400 10 $254.28 

11641 10 $493.68

11313 0 $384.39 

11640 10 $416.36

11312 0 $330.86 

11626 10 $852.79

11311 0 $229.00 

11624 10 $704.84

11310 0 $233.46 

11623 10 $624.54

69650 90 $1,722.69

69405 10 $558.37 

69420 10 $408.18 

69661 90 $2,586.64

69421 10 $318.22 

69662 90 $2,476.60

69424 0 $271.38 

69666 90 $1,733.10

69433 10 $432.72 

69667 90 $1,736.07

69436 10 $343.50 

69670 90 $2,023.06

69440 90 $1,478.08 

69676 90 $1,782.17

69450 90 $1,165.81 

69700 90 $1,469.90

69501 90 $1,568.79 

69710 XXX $0.00

69502 90 $2,084.77 

69711 90 $1,848.34

69505 90 $2,565.82 

69714 90 $2,306.34

69511 90 $2,628.27 

69715 90 $2,848.35

69530 90 $3,525.68 

69717 90 $2,420.84

69535 90 $5,733.87 

69718 90 $2,878.09

69540 10 $445.36 

69720 90 $2,558.38

69550 90 $2,219.35 

69725 90 $4,032.74

69552 90 $3,349.47 

69740 90 $2,503.36

69554 90 $5,387.40 

69745 90 $2,662.47

69601 90 $2,243.14 

69799 YYY $0.00

69602 90 $2,333.10 

69801 0 $418.59

69603 90 $2,686.27 

69805 90 $2,260.98

69604 90 $2,384.40 

69806 90 $2,030.50

69605 90 $3,326.42 

69820 90 $1,837.93

69610 10 $820.82 

69620 90 $1,471.39 

69905 90 $1,968.79

69840 90 $1,898.16

69631 90 $1,894.44 

69910 90 $2,182.17

69632 90 $2,311.54 

69915 90 $3,303.37

69633 90 $2,235.70 

69930 90 $2,626.04

69635 90 $2,627.53

 69949 YYY $0.00

69636 90 $2,940.54 

69950 90 $3,823.08

69637 90 $2,930.88 

69955 90 $4,243.90

69641 90 $2,232.73 

69960 90 $4,128.66

69642 90 $2,866.19 

69970 90 $4,596.32

69643 90 $2,623.81 

69979 YYY $0.00

69644 90 $3,151.70 

69990 ZZZ $461.71

69660 90 $1,985.89

SURGERY GROUND RULES

SURGERY AND FOLLOW-UP CARE PROVIDED BY DIFFERENT HEALTH CARE PROVIDERS: When one health care provider performs the surgical procedure and another provides the follow-up care, the value may be apportioned between them by agreement. Whether the amount charged is for the procedure, or the follow-up care should be clearly indicated. The "global fee" is not to be increased, but prorated between the health care providers.

REPEAT PROCEDURE BY ANOTHER HEALTH CARE PROVIDER: A basic procedure performed by one health care provider may have to be repeated by another. Identify and submit an explanatory note. 

PRORATION OF SCHEDULED FEE: When the schedule specifies a unit value for a definite treatment and the patient is transferred from one health care provider to another, the applicable Unit Value is to be apportioned between the health care providers. The providers involved shall agree upon the amount of the proration, and shall render separate bills accordingly with an explanatory note.  

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health care provider (e.g., sterile trays, drugs) over and above those included with the office visit or other services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays, supplies, and materials provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. 

 SURGICAL IMPLANTABLES: Reimbursement for surgical implantable items (e.g. rods, pins, screws, plates, prosthetic joint replacements) and which are made of plastic, metallic, or of autogenous/non-autogenous graft material are to be determined by cost to the provider plus a 25% markup above the invoice cost. A copy of the invoice(s) (date of purchase within twelve months of implantation) must be submitted with the bill. Costs of postage and delivery are not reimbursable.

SURGICAL ASSISTANT: Non-physician surgical assistants such as physician assistants or registered nurses, who are either certified or licensed by the Kansas State Board of Healing Arts, the Kansas State Board of Nursing, or some other comparable State licensing agency, may bill at 10% of the code fee. The code(s) must coincide with those of the primary surgeon who must be identified as the responsible physician. Such services are to be identified by adding modifier -NP to the procedure code. 

Additionally, bills for any other surgical services (i.e. repair of a minor laceration) provided by non-physicians such as physician assistants or registered nurses must be submitted on the CMS 1500 or an equivalent form containing the same information. The form must also clearly identify the responsible physician.

OTHER FEES: The Unit Values for anesthesia, x-rays, laboratory procedures, consultation and other medical services, and office and hospital visits are listed in the following sections: Anesthesia, Radiology, Pathology and Laboratory, Medicine, Physical Medicine and Rehabilitation, and Evaluation and Management.  

MEASUREMENTS: When listed with a described procedure, measurements pertain to the original wounds or defects before any treatment is effected. The allowable charge includes creation of any additional defect. The necessary preparations for repair do not merit an additional charge. The depth of a wound is not a factor in the measurements when the described procedure is stated in terms of length or area. 

MODIFIERS: Procedure codes for surgery may be modified under certain circumstances. The circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code. Refer to Appendix A - Modifiers for a list of modifiers that may be used.