What is the main requirement for applying Modifier 53?

Applying Modifier 53, which indicates a discontinued procedure, requires that there be thorough documentation of the surgical procedure's progress prior to its termination. This is crucial because the modifier is used when a surgical procedure is started but then stopped due to specific circumstances, such as the patient's condition or unexpected occurrences during the surgery.

Proper documentation must clearly outline what transpired during the procedure before it was discontinued. This ensures that there is a legitimate clinical reason for not completing the surgery, which is essential for billing and coding compliance. Without this record of the steps taken and the context of the situation, it would be challenging to justify the application of Modifier 53, potentially leading to claims denials or issues with reimbursement.

The other options do not capture the essence of what is essential for Modifier 53. While patient consent, proof of emergency circumstances, and completion notes may play roles in various clinical scenarios or other modifiers, they do not directly address the specific documentation requirements related to the progress of the procedure itself prior to its termination.