# Modifier 33 - billing for Colonoscopy



## sbarrila (Mar 17, 2011)

I posted this in the modifier thread and received no response.  Was hoping someone might have some info on this new modifier:


Has anyone used the 33 modifier when billing for Colonoscopy and/or EGD for a facility? Is so what payer(s) did you bill to and did the claims process correctly? Thank you


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## ASC CODER (Mar 18, 2011)

The new outpatient CPT modifier 33 is the "most noteworthy" change in CMS' Outpatient Code Editor Version 12.1, effective April 4, according to an AAPC report. 

Modifier 33 Preventive services is effective retroactively Jan. 1, 2011, according to CMS. The modifier can be used with CPT and HCPCS Level II prevention codes but not with codes for services that are inherently preventive.

The American Medical Association developed the modifier in order to meet a requirement of the Patient Protection and Affordable Care Act that mandates healthcare insurance plans cover preventive services and immunization without any cost-sharing. Modifier 33 was created to allow providers to demonstrate to payors that the service was preventive under applicable laws with no patient cost-sharing. 

The AMA's example is a screening colonoscopy (45378) resulting in a polypectomy (45383). The official AMA description of modifier 33 can be found here. 

Read the AAPC report on modifier 33.


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## SS62 (Mar 18, 2011)

Hi 
I dont see a Modifier -33 in the "Approved for ASC" listing.  The only mod I am aware of that is new for colonoscopy is the -PT mod for Colonoscopy screening that turned diagnostic.   Where are you reading about -33?  I have never seen that.  Thanks.


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## j.berkshire (Mar 18, 2011)

Here is the AMA instruction on modifier 33:  http://www.ama-assn.org/ama1/pub/upload/mm/362/new-cpt-modifier-for-preventive-services.pdf.  It is used for commercial payer claims and  alerts the processing system to waive all cost shares associated with the listed preventive services.  The modifier is in response to provisions in PPACA and is not listed in the CPT 2011 manual.


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## SS62 (Mar 18, 2011)

Thanks for the link J...


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## sholzgrafe (Jun 3, 2011)

*modifier 33*

I have a [patient that went in for a screening colonoscopy and ended up having polyps removed.  He has Pekin insurance.  I have talked to them about using the 33 modifier for this claim.  They told me since he had polyps removed he would have to pay the co-pay and deductible.  It is my understanding that since it was originally a screening he should not have out-of-pocket expense under the PPACA Act.  Pekin would not recognize AMA's rule about this siutation.  Has anyone experienced this problem?  Does anyone know where I can go on a government website that explains how this would work or does the patient simply owe the money?  Pekin will not change they decision unless I find something from the government stating that with the 33 modifer they have to pay for the polyp removal since it was origanly a screening code.  Thanks


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## ASC CODER (Jun 3, 2011)

Modifier -33 is new for 2011 and is not published in most CPT books, as it was approved for use by the American Medical Association after the 2011 books were printed. Check with your local carriers for specific use or requirements before using modifier -33.




Modifier 33 Preventive services is effective retroactively Jan. 1, 2011, according to CMS. The modifier can be used with CPT and HCPCS Level II prevention codes but not with codes for services that are inherently preventive.


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## sholzgrafe (Jun 6, 2011)

*modifier 33*

I explained to Pekin about the modifier 33 and offered to fax them the article from AMA describing the billing procedures for modifier 33.  The supervisor in charge told me she did not want the article because she didn't care what AMA said.  They followed the federal guildelines.  I need to find somewhere on a federal law website that explains the use of the 33 modifier and its use with a colonoscopy.  I was suprised she said that about AMA since they write the CPT book.  I am at a loss of what to do.  Thanks for any info anyone can give me.


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## ASC CODER (Jun 6, 2011)

New Modifier 33 in OCE Update
March 15th, 2011 
The new outpatient CPT® modifier 33 is one of the many changes announced in the latest update to the Outpatient Code Editor Version 12.1, effective April 4, 2011, by the Centers for Medicare & Medicaid Services (CMS), but it's the most noteworthy. Modifier 33 Preventive services is effective retroactively Jan. 1, 2011, according to CMS Transmittal 2172. The modifier is not in the CPT® 2011 Professional Edition code book. It can be used with both CPT® and HCPCS Level II prevention codes, but should not be appended to codes for services that are inherently preventive.

The modifier was developed by the American Medical Association (AMA) to assist in fulfilling an aspect of the Patient Protection and Affordable Care Act (PPACA). The PPACA requires all health care insurance plans to begin covering preventive services and immunization without any cost sharing. These benefits go into effect when plans renew or change. AMA says modifier 33 was created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws with no patient cost-sharing. AMA's example is a screening colonoscopy (45378) resulting in a polypectomy (45383). However, if the service is inherently preventive, such as a screening mammography, modifier should not be appended.

The official AMA description is as follows:

Modifier 33, Preventive Service: 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 service. For separately reported services specifically identified as preventive, the modifier should not be used.


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