# Modifier 33 - CPT Symposium



## kbartrom

At AMA's CPT Symposium we were told of a new modifier: 33. The new modifier was to be appended to new preventive services.  Has anyone seen additional infomation regarding this?


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## pvang

*More info anyone?*

I was just about to post up the exact same question until I saw someone already beat me to it  

Can anyone shed some light on this? Thanks bunches!

PVang


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## mitchellde

Yes I can this is what was posted by the AMA on Nov 12:
New CPT Modifier for Preventive Services
The implementation of health care reform regulations has begun with a significant change involving preventive services. The Patient Protection and Affordable Care Act (PPACA) requires all health care insurance plans to begin covering preventive services and immunizations without any cost‐sharing, ie, they must provide first-dollar-coverage for certain specified preventive services. The timing of this being implemented is dependent on when health insurance plans renew or change. The regulations specify that plans cannot impose cost-sharing requirements, such as co-pays, coinsurance, or deductibles with respect to specified preventive services in which preventive services are billed separately. When these services are part of an office visit, the office visit may not have cost-sharing if the primary reason for the visit is to receive preventive services. However, cost-sharing is permitted for an office visit when the office visit and covered preventive services are billed separately, and the primary purpose of the office visit is not delivery of the covered preventive services.
In addition, insurance plans are permitted to impose cost-sharing (or choose not to provide coverage) for recommended preventive services if they are provided out-of-network. Not all services that some or many clinicians consider as preventive are included in the law. For preventive services not covered in the statute and regulations, plans are permitted to require cost-sharing. The new mandate may also affect payer coverage or payment policies for services listed in the Counseling Risk Factor Reduction and Behavior Change Intervention section of CPT (99401-99429).
In response to this PPACA requirement, CPT modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws, and that patient cost-sharing does not apply. This modifier assists in the identification of preventive services in payer-processing-systems to indicate where it is appropriate to waive the deductible associated with copay or coinsurance and may be used 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).
Note that Medicare has created HCPCS II codes for some services, and effective after January 1, 2011, and should be appended to codes representing the preventive services, unless the service is inherently preventive, eg, a screening mammography or immunization advised by the Advisory Committee on Immunization Practices (ACIP). If multiple preventive medicine services are provided on the same day, the modifier is appended to the codes for each preventive service rendered for the day.
The CPT modifier’s descriptor has additional non-Affordable Care Act (ACA)-specific language for states or other mandates that have similar insurance benefit requirements for other services than those covered in the federal law. For example, if a state mandates first-dollar-coverage for PSA screening, the modifier would be appropriate to use for insureds with plans affected by the mandate. It is hoped that the modifier will create less reliance on combining complex procedures and diagnosis codes without diminishing the importance of correct diagnostic coding.
Modifier 33, Preventive Service: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 appending modifier 33 Preventive Service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
CPT modifier 33 is applicable for the identification of preventive services without cost-sharing in these four categories:
1.Services rated “A” or “B” by the US Preventive Services Task Force (USPSTF) (see Table 1) as posted annually on the Agency for Healthcare Research and Quality’s Web site: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm;
2.Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
3.Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics) as supported by the Health Resources and Services Administration; and
4.Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration.
Services with ‘A’ or ‘B’ ratings by the USPSTF are services that are recommended to be offered or provided. Services that are graded with an ‘A’ rating have been judged to have a high certainty that the net benefit is substantial. Services that are graded with a ‘B’ rating have been judged to have a high certainty of moderate to substantial net benefit.
A complete listing of the USPSTF-rated service categories with relevant CPT and HCPCS codes and grades is listed below. HCPCS codes should be used to describe services provided for Medicare and Medicaid beneficiaries. Services for patients covered by private insurance should be reported with CPT codes, when applicable.
US Preventive Services Task Force. USPSTF A and B Recommendations. August 2010. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
The following examples illustrate common situations involving preventive services and how they are handled.

•
A 45-year-old male individual receives a cholesterol-screening test, which is a recommended preventive service, during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services.
•
An individual receives a recommended preventive service that is not billed as a separate charge. The primary purpose for the office visit is a recurring abdominal pain and not the delivery of a recommended preventive service. Therefore, the plan or issuer may impose cost-sharing requirements for the office visit.
•
An individual receives a recommended preventive service that is not billed as a separate charge, ie, it is part of the office visit and the delivery of said service is the primary purpose of the office visit. Therefore, the plan or issuer may not impose cost-sharing requirements for the office visit.
•
Treatment resulting from a preventive screening can be subject to cost-sharing requirements, if the treatment is not in itself a recommended preventive service.
For a comprehensive list of recommendations and guidelines covered by the Regulations visit, www.healthcare.gov/center/regulations/prevention/recommendations.html.
Reference
1. American Federation of State, County, and Municipal Employees, AFL-CIO. Patient Protection and Affordable Care Act of 201: Coverage of Services.Washington, DC:2010. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm


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## mitchellde

Yes I can this is what was posted by the AMA on Nov 12:
New CPT Modifier for Preventive Services
The implementation of health care reform regulations has begun with a significant change involving preventive services. The Patient Protection and Affordable Care Act (PPACA) requires all health care insurance plans to begin covering preventive services and immunizations without any cost‐sharing, ie, they must provide first-dollar-coverage for certain specified preventive services. The timing of this being implemented is dependent on when health insurance plans renew or change. The regulations specify that plans cannot impose cost-sharing requirements, such as co-pays, coinsurance, or deductibles with respect to specified preventive services in which preventive services are billed separately. When these services are part of an office visit, the office visit may not have cost-sharing if the primary reason for the visit is to receive preventive services. However, cost-sharing is permitted for an office visit when the office visit and covered preventive services are billed separately, and the primary purpose of the office visit is not delivery of the covered preventive services.
In addition, insurance plans are permitted to impose cost-sharing (or choose not to provide coverage) for recommended preventive services if they are provided out-of-network. Not all services that some or many clinicians consider as preventive are included in the law. For preventive services not covered in the statute and regulations, plans are permitted to require cost-sharing. The new mandate may also affect payer coverage or payment policies for services listed in the Counseling Risk Factor Reduction and Behavior Change Intervention section of CPT (99401-99429).
In response to this PPACA requirement, CPT modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws, and that patient cost-sharing does not apply. This modifier assists in the identification of preventive services in payer-processing-systems to indicate where it is appropriate to waive the deductible associated with copay or coinsurance and may be used 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).
Note that Medicare has created HCPCS II codes for some services, and effective after January 1, 2011, and should be appended to codes representing the preventive services, unless the service is inherently preventive, eg, a screening mammography or immunization advised by the Advisory Committee on Immunization Practices (ACIP). If multiple preventive medicine services are provided on the same day, the modifier is appended to the codes for each preventive service rendered for the day.
The CPT modifier's descriptor has additional non-Affordable Care Act (ACA)-specific language for states or other mandates that have similar insurance benefit requirements for other services than those covered in the federal law. For example, if a state mandates first-dollar-coverage for PSA screening, the modifier would be appropriate to use for insureds with plans affected by the mandate. It is hoped that the modifier will create less reliance on combining complex procedures and diagnosis codes without diminishing the importance of correct diagnostic coding.
Modifier 33, Preventive Service: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 appending modifier 33 Preventive Service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
CPT modifier 33 is applicable for the identification of preventive services without cost-sharing in these four categories:
1.Services rated â€œAâ€� or â€œBâ€� by the US Preventive Services Task Force (USPSTF) (see Table 1) as posted annually on the Agency for Healthcare Research and Quality's Web site: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm;
2.Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
3.Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics) as supported by the Health Resources and Services Administration; and
4.Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration.
Services with â€˜A' or â€˜B' ratings by the USPSTF are services that are recommended to be offered or provided. Services that are graded with an â€˜A' rating have been judged to have a high certainty that the net benefit is substantial. Services that are graded with a â€˜B' rating have been judged to have a high certainty of moderate to substantial net benefit.
A complete listing of the USPSTF-rated service categories with relevant CPT and HCPCS codes and grades is listed below. HCPCS codes should be used to describe services provided for Medicare and Medicaid beneficiaries. Services for patients covered by private insurance should be reported with CPT codes, when applicable.
US Preventive Services Task Force. USPSTF A and B Recommendations. August 2010. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
The following examples illustrate common situations involving preventive services and how they are handled.

•
A 45-year-old male individual receives a cholesterol-screening test, which is a recommended preventive service, during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services.
•
An individual receives a recommended preventive service that is not billed as a separate charge. The primary purpose for the office visit is a recurring abdominal pain and not the delivery of a recommended preventive service. Therefore, the plan or issuer may impose cost-sharing requirements for the office visit.
•
An individual receives a recommended preventive service that is not billed as a separate charge, ie, it is part of the office visit and the delivery of said service is the primary purpose of the office visit. Therefore, the plan or issuer may not impose cost-sharing requirements for the office visit.
•
Treatment resulting from a preventive screening can be subject to cost-sharing requirements, if the treatment is not in itself a recommended preventive service.
For a comprehensive list of recommendations and guidelines covered by the Regulations visit, www.healthcare.gov/center/regulations/prevention/recommendations.html.
Reference
1. American Federation of State, County, and Municipal Employees, AFL-CIO. Patient Protection and Affordable Care Act of 201: Coverage of Services.Washington, DC:2010. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm


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## dballard2004

Thanks so much Debra!

I have read this info, but I am still unclear as to how to correctly use this modifier.  If I understand correctly, if it is a preventative service where no co-pay applies, you use this modifier?  Would you use this modifier on the preventative E/M codes?  Can someone shed some light here please?

I went to the CPT Changes workshop last month and this modifier was never mentioned and it is also not in the 2011 CPT manual.


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## kbartrom

I agree with Dawson - thanks much for the info but still a bit unclear.  Is CMS expecting use of this modifier in 2011?  Commercial carriers?  In the first example given:

_A 45-year-old male individual receives a cholesterol-screening test, which is a recommended preventive service, during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services._

...is the modifier used on the cholesterol test?


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## mitchellde

I really wish I kew the answers!  This was the info I found early in December on the AMA website, I was surprised to see it was not in my new CPT book but then the modifier was created its says Nov 12.  There is no other information anywhere about this modifier.  I have been on every major carrier website and there is no mention.  CMS has nothing either.  I have my interpretation but I hesitate to apply it as I may be way off base.
My suggestion?
Contact every payer you work with and query as to whether they will be expecting/accepting the 33 modifer and if so in what circumstances.  
If anyone else out there has anything on this please ring in and please give a source for the information.


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## Jagadish

http://www.ama-assn.org/ama1/pub/upload/mm/362/new-cpt-modifier-for-preventive-services.pdf

Please find an updated link from AMA website for the usage of modifier 33.


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## dballard2004

Is this modifier being recongnized/required by payers?


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## MMAYCOCK

It's my understanding that codes created specifically for preventive services like the new wellness visit code do not need this modifier. It says that inherently preventive codes do not require it. 
It is required when the system cannot tell if this is a procedure that meets the federal guidelines for waiver of patient cost sharing 
"The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383). The 45378 should be appended with the modifier 33. 
I have not found any other payers who are recognizing the 33 yet. It seems like medicare/medicare advantage are the only ones using it right now.


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## rsboggs

I thought that the modifier PT was to be attached to a preventative colonoscopy that then turned diagnostic. This is the first I have heard of the 33 modifier?


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## kbartrom

Are all Medicare carriers expecting use of this modifier?  Seems as if there would be more education...


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## mitchellde

PT is for Medicare and 33 is for all other payers


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## laurasullivan

*Looking for Medicare policy*

I have read the AMA documentation on the new modifier, but I can't find anything on CMS or Palmetto.gba (our MAC) on the use of this modifier.

Does anyone have a link to the Medicare policy on this?

thanks


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## Mklaubauf

*33 as it related to V12.72*

Does anyone have any documentation if V12.72 is considered preventive under the colorectal screening under the U.S. Task Force.  I'm not sure if we do a colonoscopy for V12.72 and find nothing, if we should use modifier 33?

Any thoughts
M. Klaubauf, CPC


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## Jacky

What about modifier "PT"  I thought this was a new modifier that was added to colonoscopies when they turned from screening do diagnostic?  How is this different from "33"


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## Jacky

Does anyone know about modifier PT?  that was suppose to be new and serve the same purpose.


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## kbartrom

It was noted above that the PT modifier is for Medicare and 33 for all other payers.  Is there documentation to support this?  I did find the following on the ASC Review website:

_A new HCPCS modifier takes effect Jan. 1, 2011, for use in cases where a screening colonoscopy or screening flexible sigmoidoscopy was planned, but clinical findings leads to a diagnostic colonoscopy, according to the Ambulatory Surgery Foundation.

 Modifier –PT will "prompt the claims processing system to waive the deductible for ALL surgical services on the same date of service as the diagnostic service," according to the ASF. "Unlike the additional waiver of copayments and coinsurance for straight screening services allowed by the Patient Protection and Accountable Care Act, if the planned screening service becomes a diagnostic service, only the deductible is waived."

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions._


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## mitchellde

from the december CPT assistant:
In response to this PPACA requirement, CPT modifier 33 has been created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws, and that patient cost-sharing does not apply. This modifier assists in the identification of
preventive services in payer-processing-systems to indicate where it is appropriate to waive the deductible associated with copay or coinsurance and may be used 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).*
Note that Medicare has created HCPCS II codes for some of these preventive medicine services. *CPT modifier 33 is effective after January 1, 2011, and should be appended to codes representing the preventive services, unless the service is inherently preventive, eg, a screening mammography
or immunization recognized by the Advisory Committee on Immunization Practices (ACIP). If multiple
preventive medicine services are provided on the same day, the modifier is appended to the codes for each preventive service rendered on that day.


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## kbartrom

Ok, slowly but slowly putting this together.  I was surprised that modifier 33 would be required but there has been little education (other than here on the forum!).  The following explains:
PPACA specifies that *group health plans or insurance coverage existing on the date of enactment (March 23, 2010) are not required to comply with certain plan requirements under PPACA. These include, for example, the requirement for coverage of preventive care at no cost to the participant or insured*. As explained in the preamble to the IFR, however, PPACA does not address at what point changes to such group health plan or health insurance coverage are significant enough to cause the plan or health insurance coverage to cease to be a grandfathered plan, leaving that question to regulatory guidance. 

The interim final regulations (IFR) set out the specific requirements that a group health plan or insurance carrier must comply with in order to maintain status as a “grandfathered” plans. In general, the rules provide that grandfather plans will lose their status if “they choose to make significant changes that reduce benefits or increase costs to consumers”,


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## MMAYCOCK

I need to correct that. It's beginning to seem that 33 is for E&M and PT is for surgical procedures. 
PT is a modifier specifically for this purpose: 
In the final rule, CMS created for Medicare a new Healthcare Common Procedure Coding System (HCPCS)modifier-PT (CRC screening test, converted to diagnostic test or other procedure) to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code, or as a result of the barium enema when the screening test becomes a diagnostic service. 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. Coinsurance for Medicare beneficiaries 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.


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## Claudia Yoakum-Watson

There is a fair amount of confusion on the intended use of Modifiers 33 and PT.  

I’ll talk about Modifier 33 first.  The short answer to when you are to use Modifier 33 is on "preventive services".  The long answer is in Michellde's post from 1-3-11.  I've included an excerpt at the bottom of this page.  

Insurance carriers have known about this for awhile because they had to identify preventive services that were included in the mandate.  I have worked with a group of carriers to identify how they were going to do that.  My experience is that carriers have identified these services by CPT, HCPCS, and/or ICD codes or a combination of these.  So they don't "need" the Modifier 33 to identify preventive services that have no cost sharing.  
From a coding perspective, we should use Modifier 33 when applicable.  

OK - now Modifier PT.  First, although Modifiers 33 and PT seem to be connected, they identify different things.  Stick with me here. 

Modifier 33 identifies screening/preventive services.   Modifier PT is used to identify when a "screening/preventive" services turns into a diagnostic/theraputic service. 

The most common example for Modifier PT would be when a person has a screening colonoscopy and a polyp is found.  If the polyp is removed, the "screening" turns into a therapeutic procedure.  In this situation, Modifier PT is used to identify that the procedure started as a screening but ended up a therapeutic procedure.  Medicare will waive the deductible in this situation.  This is not part of the USPSTF mandate.  


_CPT modifier 33 is applicable for the identification of preventive services without cost-sharing in these four categories:

1.Services rated “A” or “B” by the US Preventive Services Task Force (USPSTF) (see Table 1) as posted annually on the Agency for Healthcare Research and Quality’s Web site: http://www.uspreventiveservicestaskf...spsabrecs.htm;

2.Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

3.Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics) as supported by the Health Resources and Services Administration; and

4.Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration.

US Preventive Services Task Force. USPSTF A and B Recommendations. August 2010. Available at: http://www.uspreventiveservicestaskf...uspsabrecs.htm._


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## baubry

*Modifier 33*

45378 is a diagnostic colonoscopy so 33 does not belone appended - even if it was in the AMA example. A test does not go from diagnostic to screening. If they used the G code for screening colonoscopy, and a polepectomy followed, it seems to me that 33 is appended to the polepectomy because it was the result of a screening service? Very confusing. I looked at some of the CPT F codes that might work such as 4158F 'patient counseled about risks of alcohol abuse' because it meets an A criteria but still not positive. Anyone esle have any ideas?


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## baubry

*Modifier 33*

More on modifier 33. But still unclear: I do not think payers want therapeutic services to be co pay free. Main problem is that the preventative services on the PPACA list do not have codes. Any E/M services that also includes screening could possible use modifier 33?
--------------------------------------------------------------------------------------------------------

There is a new modifier in town, and its number is 33. Because of the Patient Protection and Affordable Care Act (PPACA), there is now a requirement for health insurance plans to cover preventive services without any cost sharing (meaning no copays, coinsurance or deductibles applying).

What constitutes a preventive service as defined by the PPACA? Services that the US Preventive Services Task Force (USPSTF) deems a grade A (defined as “high certainty that the net benefit is substantial”) and grade B (defined as “high certainty that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial”). The list of grade A and B recommendations can be found on the USPSTF website at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm  Modifier 33 should be applied to any of these services when they are provided.

The December 2010 CPT Assistant contains an article that lists the USPSTF A and B recommendations. The article also highlights an interesting situation, when a screening colonoscopy results in a polypectomy. Because the service that was initiated was a preventive service, the recommendation of the article is to use a 33 modifier on the CPT code for the polypectomy. This also would apply to any other service that was initiated as a preventive service but becomes a therapeutic service.

Remember CPT Assistant is available for Audit & Revenue Resource Center users and Coding and Revenue Resource Center users. Look for the link in the Hot Resources section on the main page.


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## CJG

*Modifier 33*

I was told this modifier was not to be used in the ASC.  I'm not certain that is correct.  It's not listed as a modifier that is to beused in the ASC  in the CPT but then it's not listed in the CPT all.  I've read the updated release from the AMA but it doesn't specifically state use in the ASC is allowed.


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## skildare

My biggest confusion with this modifier is regarding screening turned diagnostic colonoscopies.  The May issue of Coding Edge included an article "Modifier 33 Arrives Quietly But Packs a Punch."  This piece stated that PT is to be used for Medicare, 33 is for commericial payers.  I have recently began using 33 for non-Medicare colonoscopy claims.  These are performed in an ASC and so far I have not had a problem.


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## lavonneh

*Modifier 33*

When it is stating (cost sharting)  is that the same as split billing? 
Would like more clarification on this cost sharing factor, please!

thank you
Lavonne H


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## Lkimsey

*Modifier 33*

I have had numerous inquiries about this modifier when I introduced it at our CPT Update workshop.  I have not found any carriers including Medicare that are recognizing this modifier.  I have told my clinics that until more information comes forth to not use this modifier to eliminate the denials for not valid modifier.  I am in Louisiana and our carrier is even denying it.  Lynn Kimsey, CPC, CPMA, CPC-I, CEMC


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## Eagle Eye

*Modifier 33*

CMS does not recognize this modifier, although Anthem Products do. From how I understand it the note must specifically state that the is screening for high blood pressure (ex V81.1 or V17.49) the record cannot just show generalized screening code V70.0. If anyone can find any information to either confirm or prove this wrong, please let me know.  Thanks

I stand corrected. I just found an update on the CMS website.Pub 100-04 Medicare Claims Processing Transmittal#2172 Change Request#7344 Appendix M the effective date is 01/01/11 to add modifier 33 to the valid modifier list list. Pub 100-20 One-Time Notification Transmittal#864 gives a list of which Preventative Services with the CPT® Codes will waive/not waive the patient's portion.


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## MLHANNA

*Modifier 33 article*

In reply to whether or not modifier 33 should be used for E/M, I found this article, which says the answer is "YES".  However, I feel that since each insurance company has limitations on how often a patient can receive a screening that appending this modifier should be reserved for the procedure, rather than the pre-procedural visit, as I don't think they'll wave the coins for both and the procedure would obviously be more costly.

Please see below:

--- Article Information ---
This article was printed from Codapedia™ - The collaborative online encyclopedia for medical coding and reimbursement.
Article's URL: http://codapedia.com/article.cfm?id=561
---------------------------

Modifier 33 and Modifier PT
how and when to use these modifiers
By: Codapedia Editor (Fri, Mar/02/2012) 


In 2011, both CPT® and CMS developed a new modifier in response to provisions of the Affordable Care Act (ACA)  passed in 2010.  The modifier was developed late enough in 2010 that it wasn't included in the 2011 CPT® book, although it was a valid modifier for that year.  The ACA mandated that any service that received an A or B rating from the US Preventive Services Task Force (USPSTF) be paid without co-pay or deductible for Medicare patients. Also, any group insurance plans that renewed or started after September 2010 that did not claim “grandfathered” status must also include first dollar coverage for services which the USPTF graded as A or B.  According to the AMA document on modifier 33, when providing these A or B rated services are “part of an office visit, the office visit may not have cost-sharing if the primary reason for the visit is to receive preventive services.”

The USPSTF is a function of the Department of Health and Human Services.  According to their statement, “The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."”   The USPSTF reviews scientific literature and then makes recommendations for screening services.  You can find a list of their current recommendations on their website at

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

Modifier 33, Preventive Service: When the primary purpose of the service is the delivery of an evidenced-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 appending modifier 33, Preventive Services, to the service.  For separately reported services specifically identified as preventive, the modifier should not be used.  

Use modifier 33 on the preventive medicine service/office visit and on any of the screening tests identified on the list from the USPSTF.  This tells the payer that these are preventive services, and should prevent the payer from assessing a co-pay or deductible.  The patient will have full coverage.  Use a diagnosis code for the examination, such as V70.0, V20.2, or V72.31.  

Practices should still verify coverage and benefits prior to the visit.

Modifier PT is a HCPCS modifier intended to be used when a scheduled colorectal screening test becomes a therapeutic or diagnostic service.  Why would this be needed?   Because a screening test has first dollar coverage and a therapeutic or diagnostic test will be subject to co-pay or deductible.  Medicare instructs medical practices to use HCPCS codes for colorectal screening (for example, G0105, among others.)  But if an abnormality is found and a biopsy is taken or a polyp removed, the surgeon uses a CPT® code in the family of codes starting with 37….  In that case, use the CPT® code, append modifier PT to the service and the patient will not be charged a co-pay or deductible.  CMS's quick reference guide to preventive services states, “No deductible for all surgical procedures (CPT® code range of 10000 to 69999) furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services. Modifier PT should be appended to at least one CPT® code in the surgical range of 10000 to 69999 on a claim for services furnished in this scenario.

--- end ---


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## znarema

*modifier 33*

Can anyone please tell me if modifer 33 can be used on capitated patients/plan?


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## skintzley

does anyone know if this modifier is needed on anesthesia claims? and if it takes the place of any current required modifiers (QS, GZ)???


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## shariblove

*modifier 33 anesthesia*

yes as of 1/1/15 it applies to anesthesia I hope the following link will get you to their website.
http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM8874.pdf

Also, I had this sent to me by my supvr.
Modifiers 33 and PT for colonoscopies-mod 33 is when screening colonoscopy done, no polyp found. Medicare pays 100% of the screening and anesth., no copay, no deductible. Mod 33 is secondary modifier to the anesth mods.  Mod PT is when screening is done and a polyp is found. Medicare pay 80% and patient must pay copay; however the pt doesn not have to pay the deductible even if a polyp is found. PT is also a secondary modifier.

Hope that helps!


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## Billing500

All of our anesthesia claims are being denied by Medicare when billing:
00810 AA QS PT
The 33's are being paid correctly, though.

The "senior CMS rep" has directed me to a January 2015 Release - Part B document which only calls for modifier 33 to be used for anesthesia associated with screening colonoscopy.  She further said that only the provider doing the actual colonoscopy should be billing with a PT.

I've seen many other sites (including some fairly well known anesthesia sites), which list PT as the modifier which should be used in cases where polyps were removed or a biopsy was taken.

Has anyone else had trouble with denials when using modifier PT??  Please weigh in.


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