CMS Pub. 100-04, ch. 4, § 20.6.4

73: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure

prior to the administration of anesthesia

74: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure

after administration of anesthesia

A. General

Modifiers 73 and 74 provide a way for hospitals to report and be paid for expenses

incurred in preparing a patient for a procedure and scheduling a room for performing the

procedure where the service is subsequently discontinued. This instruction applies to both

hospital outpatient departments (HOPDs) and to ambulatory surgical centers (ASCs).

Modifier 73 is used by the facility to indicate that a 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 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.

This modifier may also be used to indicate that a planned surgical or diagnostic procedure

was discontinued, partially reduced or cancelled at the physician's discretion after the

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, 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.

Coinciding with the addition of the modifiers 73 and 74, modifiers 52 and 53 were

revised. Modifier 52 is used to indicate partial reduction, cancellation, or discontinuation

of services for which anesthesia is not planned. The modifier provides a means for

reporting reduced services without disturbing the identification of the basic service.

Modifier 53 is used to indicate discontinuation of physician services and is not approved

for use for outpatient hospital services.

Note that the elective cancellation of a procedure should not be reported.

Modifiers 73 and 74 are only used to indicate discontinued procedures for which

anesthesia is planned or provided.

B. Effect on Payment

Procedures that are discontinued after the patient has been prepared for the procedure and

taken to the procedure room but before anesthesia is provided will be paid at 50 percent

of the full OPPS payment amount. Modifier 73 is used for these procedures. As of

January 1, 2016, for device-intensive procedures that append modifier 73, we will reduce

the APC payment amount for the discontinued device-intensive procedure by 100 percent

of the device offset amount prior to applying the additional payment adjustments that

apply when the procedure is discontinued as modified in the CY 2016 OPPS/ASC final

rule that was published in the November 13, 2015 “Federal Register” (80 FR 70424-

70426). Beginning January 1, 2017, device-intensive procedures are defined as those

procedures requiring the insertion of an implantable device that also have a HCPCS-level

device offset greater than 40 percent. From January 1, 2016, through December 31, 2016,

device-intensive procedures were defined as those procedures that involve implantable

devices that are assigned to a device-intensive APC (defined as those APCs with a device

offset greater than 40 percent). Beginning January 1, 2019, device-intensive procedures

are defined as procedures that involve the surgical implantation or insertion of an

implantable device that is assigned a CPT or HCPCS code (including single-use devices)

and has a device offset amount that exceeds 30 percent of the procedure’s mean cost.

Procedures that are discontinued, partially reduced, or cancelled after the procedure has

been initiated and/or the patient has received anesthesia will be paid at the full OPPS

payment amount. Modifier 74 is used for these procedures.

Procedures for which anesthesia is not planned that are discontinued, partially reduced, or

cancelled after the patient is prepared and taken to the room where the procedure is to be

performed will be paid at 50 percent of the full OPPS payment amount. Modifier 52 is

used for these procedures.