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Q:I recall seeing modifier 33 for a wellness exam. Is the modifier necessary? When do we use it? Also, when do we use –PT, and how are these two modifiers different?
A: I’ll start with modifier 33. You’re not alone—this modifier has created a great deal of confusion in the coding and billing community. Part of the confusion stems from the fact that modifier 33 is not in the 2011 Current Procedural Terminology (CPT) codebook, which was printed long before the American Medical Association (AMA) posted the modifier information on its Web site.
In fairness, this modifier was created in response to healthcare reform and, by necessity, came late in 2010. Additionally, the Centers for Medicare and Medicaid Services, the American Academy of Professional Coders, and the AMA continue to publish clarifications about the use of modifier 33, even though the code became applicable January 1.
Here’s what we know so far. According to the AMA, “CPT modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under the applicable laws, and that patient cost-sharing does not apply.”
To better understand this statement, let’s define the key components.
Cost-sharing does not apply. This wording simply means that a patient’s co-insurance, co-payment, and deductible are waived for the applicable services.
The Patient Protection and Affordable Care Act made it mandatory for all healthcare insurance plans to start to cover some preventive services and immunizations as part of all benefit plans. Specified preventive services are not subject to deductibles, co-insurance, and co-pays.
Modifier 33: preventive service. Modifier 33 is applied to indicate that the preventive service is one that waives a patient’s co-pay, deductible, and co-insurance. An exception is that modifier 33 does not have to be appended to those services that are inherently preventive (for instance, screening mammography).
Most of the services to which the modifier applies are not new, so the list will not surprise you. According to the AMA, CPT modifier 33 is applicable for the identification of preventive services without cost-sharing in these four categories:
- services rated A or B by the U.S. Preventive Services Task Force (USPSTF) as posted annually on the Agency for Healthcare Research and Quality’s Web site at uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm ;
- 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 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.
The specific preventive services for which cost-sharing does not apply for Medicare patients:
- the initial preventive physical examination;
- the annual wellness visit;
- pneumococcal, influenza, and hepatitis B vaccine and administration;
- screening mammography;
- screening Pap smear and screening pelvic exam;
- prostate cancer screening tests (excluding the digital rectal exam);
- colorectal cancer screening tests;
- bone mass measurement;
- medical nutrition therapy services;
- cardiovascular screening blood tests;
- diabetes screening tests;
- ultrasound screening for abdominal aortic aneurysm;
- additional preventive services (identified for coverage through the national coverage determination; currently, these services are limited to HIV testing); and
- preventive services recommended by the USPSTF that do not have a grade of A or B, including all diagnostic clinical laboratory tests, because the deductible and co-insurance is waived on another basis.
Now to the other parts of your question.
When do we use modifier 33? The regulations specify that plans cannot impose cost-sharing requirements with respect to specified preventive services when preventive services are billed separately.
Because payers are only required to convert to the new law during their next renewal period, you will need to find out which plans have converted. Then you’ll need to identify which services they now cover as preventive; these are the services to which modifier 33 will apply. This identification will require some work on your end, payer-by-payer.
Keep in mind that services that are inherently preventive do not require the use of modifier 33.
What to do when you are billing an evaluation/management (E/M) service and preventive services for the same visit. When these services are part of an office visit, the visit may not require cost-sharing if the primary reason for the visit is to receive preventive services. Cost-sharing is permitted, however, when the office visit and covered preventive services are billed separately and the primary purpose of the visit is not delivery of the covered preventive services. In other words, when the main reason for the visit is for preventive services, co-pays, coinsurance, or deductibles will not apply.
In these situations, we understand that carriers will define the primary reason for the service by reviewing the CPT codes, modifiers, and ICD-9 codes. So correct order—and linking—of your diagnosis codes will be the key. If the primary reason for the visit was preventive, then the applicable preventive ICD-9 code (for instance, V70.0) would be listed as the primary diagnosis on the claim.
Also remember that, when deciding whether it is applicable to bill an E/M code in addition to a preventive medicine code, the CPT manual specifies that only additional work (the work over and above what normally is performed during a preventive exam) can be counted toward the E/M code level. Therefore, the E/M code level normally is no more than a level 3.
How are modifiers 33 and PT different? Confusion also has existed as to the difference between the 33 and PT modifiers. Modifier PT is to be used for a colorectal cancer screening test, converted to diagnostic test or other procedure.
So the bottom line is, modifier 33 identifies screening/preventive services, and modifier PT identifies when a screening/preventive service turns into a diagnostic/therapeutic service.
In instances in which a screening procedure has turned diagnostic, the modifier PT would be appended to the diagnostic procedure code that is reported (instead of the screening code). For Medicare, the claims processing system would respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test. Co-insurance would continue to apply to the diagnostic test and to other services furnished in connection with, as a result of, and in the same clinical encounter as the screening test. Because this is not part of the USPSTF mandate, it is unclear whether commercial carriers will follow these same guidelines.
For example, any colonoscopy, flexible sigmoidoscopy, etc. that starts out as a screening (that is, G0121, G0105) but turns into a diagnostic procedure (that is, 45385, 45384) should be coded with the diagnostic CPT code with modifier PT to show that it started out as screening. In this scenario, the patient’s deductible still will be waived, but co-insurance may now apply.