Modifier 53
Reimbursement Policy:
Modifier 53
Effective Date:
May 15, 2017
Purpose:
The purpose of this policy is to provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 53 for professional providers.
Definition:
Modifier 53 is used to indicate that the physician terminated a surgical/diagnostic procedure due to the patient’s well-being.
Scope:
All products are included, except products where Horizon is secondary to Medicare (i.e. Medigap)
All Insured and ASO accounts are included.
Policy:
Horizon BCBSNJ will reimburse discontinued procedures appropriately appended with modifier 53 at 25% of the applicable Horizon BCBSNJ fee schedule amount. Modifier 53 does not provide for reimbursement of an ineligible service.
Procedure:
Modifier 53, allow at 25% of the applicable Horizon BCBSNJ fee schedule.
No additional reimbursement will be issued if the reimbursement to the physician is via capitation or if reimbursement for such services is captured in a global rate.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
In instances where the provider is not participating, member liability shall be up to the provider’s charge.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
- Mandated or legislative required criteria will always supersede
Policy 034_v2.0_01202017
