Modifier 33 – Preventive Services usage and guideline policy

 Modifier code and Description


Modifier 33 – Preventive Services: 


Preventive Services: When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.


Tips for Billing CPT Modifier 33


The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for nongrandfathered health plans. The appropriate use of modifier 33 reduces claim adjustments related to preventive services and your corresponding refunds to members.


Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or

preventive benefits, based on the diagnosis and CPT codes submitted.


Modifier 33 should be appended to codes represented for services described in the US

Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and

Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.


The CPT® 2016 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”


1. What is modifier 33?


Modifiers are the exceptions to the rule and they are “the additional information”. They are appended directly to the applicable CPT code. In this webinar we introduced the Modifier 33, but there are others. See the following resources for a list and definition of other modifiers: http://www.codingahead.com/2009/08/list-of-modifiers.html.


Modifier 33 is applied to indicate that a preventive or screening service has taken place. The modifier may waive a patient's co-pay, deductible, and co-insurance so that there is no cost sharing. This modifier is only used on claims for commercial payers (BCBS, CIGNA, TUFTS etc). The modifier 33 does not have to be appended to those services that are inherently preventive (annual exams and preventive counseling).


Below is a list of services that the modifier 33 could be applied to. The modifier (as in all modifiers) is appended directly to the applicable CPT code.


*Services rated A or B by the U.S. Preventive Services Task Force (USPSTF);


*Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the U.S.

Department of Health and Human Services;


*Preventive care and screenings for children as recommended by the Bright Futures program of the American Academy of Pediatrics and the newborn screening recommendations of the American College of Medical Genetics as supported by the Health Resources and Services Administration (HRSA); and


*Preventive care and screenings provided for women (not included in the task force recommendations) in the comprehensive guidelines supported by the

HRSA.


Example: High-risk (for STI) patient presents to the clinic for screening but has some complaints as well. The primary reason service is screening. You bill a 99213 (append the 33 modifier) and the Z codes utilized might be Z11.3 (screening for STIs) and Z72.51 (high-risk heterosexaul behavior). 



 Anesthesia Furnished in Conjunction with Colonoscopy


Section 4104 of the Affordable Care Act defined the term “preventive services” to include “colorectal cancer screening tests” and as a result it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of the Act for screening colonoscopies. In addition, the Affordable Care Act amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or after January 1, 2011.


In the CY 2015 PFS Proposed Rule, CMS proposed to revise the definition of “colorectal cancer screening tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal. The definition of “colorectal cancer screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies in the Medicare regulations at Section 410.37(a)(1)(iii). As a result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with screening colonoscopies.


As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code 00810 performed in conjunction with G0105 and G0121) shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible:


* Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in

effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the

procedure. For separately reported services specifically identified as preventive, the modifier should not be used. 


In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But, MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.


When to use modifier 33: preventive service modifier


Modifier 33 was created in response to the preventive service requirements associated with the PPACA. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect, and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the procedure code.


For services represented by codes which may be used for either diagnostic, therapeutic or preventive services, modifier 33 must be appended to that code on the claim when the service was used for the preventive indication.


• For example, CPT code 45378, colonoscopy, may be performed for the 50-year-old asymptomatic individual as a routine screening for colorectal cancer. In this case, the colonoscopy is performed for preventive screening and modifier 33 should be appended, in addition to a well-person diagnosis code, such as V76.51.

• However, a colonoscopy, using this same code, may be performed in response to symptoms which a person exhibits. In that case, this service represents diagnostic colonoscopy.  The diagnosis code would be one which would signify the symptoms exhibited and modifier 33 would not be appended. 


When a separately submitted service is inherently preventive, modifier 33 is not used.


• Routine immunizations recommended for persons living in the United States to prevent communicable diseases are inherently preventive. Therefore modifier 33 would not be appended to these codes.

• Preventive medicine services (office visit services) represented by codes 99381-99387, 99391-99397, 99401- 99404, and 99406-99412 are distinct from problem-oriented

evaluation and management office visit codes and are inherently preventive. Therefore, modifier 33 would not be utilized with these codes.

• The CPT code for screening mammography is inherently preventive and therefore modifier 33 would not be used.


Billing Guidelines


Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance.

 

Modifier 33*The appropriate use of modifier 33 will help reduce claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 applies to commercial lines of business only.


*CPT modifier 33 is applicable to preventive services that do not have a unique code for such services (e.g., E&M codes such as, 99401 would not require modifier 33 as this code already indicates a preventive medicine service. However, code 99213 would require modifier 33 when the provider indicates that the service was preventive).


*If multiple preventive medicine services are provided on the same day, then the modifier is appended to the codes for each preventive service rendered on that day.


*Modifier 33 should be used when only preventive services were rendered on that date, not when combined with other non-preventive services.


*CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.


*CPT codes identified as inherently preventive, (e.g., screening mammography) should not be appended with modifier 33.


*This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).


Modifier PT *Modifier PT applies to Medicare products only (Medicare Advantage and Medicare Supplemental). To determine the appropriate use of modifier PT, it’s important to know why the member is presenting for treatment.


Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or other procedure (impacts colonoscopy and sigmoidoscopy codes). The appropriate use of modifier PT will help reduce claim adjustments related to colorectal screenings and your corresponding refunds to members.

Please see the following scenarios for guidance:


*Screening exam only: In a situation where a member presents for treatment solely for the purpose of a screening exam, without any signs or symptoms of a disease, then such a procedure should be considered a screening. The appropriate use of diagnosis codes and screening procedure codes is valuable in promoting appropriate adjudication of the claim. The use of the modifier PT in conjunction with a CPT procedure or HCPCS code that is defined as a screening based on that code’s description is not necessary.


*Treatment due to signs or symptoms to rule out or confirm a suspected diagnosis:


In the instance that a member presents for treatment due to signs or symptoms to rule out or confirm a suspected diagnosis, such an encounter should be considered a diagnostic exam, not a screening exam. In such a situation, the modifier PT should not be used and the sign or symptom should be used to explain the reason for the test. 


*Screening colorectal exam converted to a diagnostic service: In a circumstance where a member presents for a screening exam (without signs or symptoms), and an issue is encountered during that preventive exam, then such a circumstance would warrant the use of the PT modifier. The procedure and diagnosis codes that would typically be used in such an instance may not clearly demonstrate that the service began as a screening procedure, but had to be converted to a diagnostic procedure due to a pathologic finding (e.g., polyp, tumor, bleeding) encountered during that preventive exam. The use of the PT modifier in the instance of a screening colorectal exam being converted to a diagnostic service would clarify that despite the end result the service began as a screening service.



Reimbursement Information: 


Modifiers may be appended to CPT/ HCPCS code(s) if the service or procedure is clinically supported for use of modifiers. A claim should be submitted with the correct modifier-to-procedure code combination. Modifiers should not be appended to a CPT/HCPCS code(s) to circumvent a National Correct Coding Initiative (NCCI)

Procedure to Procedure (PTP) edit if the service or procedure is not clinically supported for the use of a modifier. Claim submissions may be denied if a claim contains an inappropriate modifier-to-procedure code combination. In this case, a corrected claim submission with the correct modifier-to-procedure code combination will be necessary to be considered for reimbursement. Medical records or other documentation should accompany the claim to ensure appropriateness of claim reimbursement.


If billing with more than one modifier, list the modifier that will impact reimbursement first.

The modifiers listed below may appear in some of the material on the applicable state plan’s provider website. The following is not an all-inclusive list and modifiers may be added or removed with appropriate notice.


MODIFIER DESCRIPTION WHEN TO APPEND A MODIFIER

33 Preventive services Append to codes represented for evidence-based services in accordance with a US Preventive Services Task Force A and B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory).

• Modifier 33 should be used for CPT codes representing preventive care services. 

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