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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