Gastroenterology Coding Alert

Not all payers are on board, so keep your eyes peeled for individual LCDs.

If you want to recoup the well-earned reimbursement that your practice deserves for preventive services, you need to know the workings of modifier 33 intimately and the appropriate situations to apply it. However, this knowledge of modifier 33 in itself will not suffice: You also need to know which payer accepts it.

Continue reading to learn when to use modifier 33 and with what payers.

Watch for Descriptors That Say ‘Screening’

You’ll use modifier 33 to communicate to your payer that your physician performed a preventive service, such as a screening for prostate cancer, and the waiving of the patient’s co-insurance, co-payment, and deductible for the applicable services.

You can only attach modifier 33 to a CPT® or HCPCS code on the U.S. Preventive Services Task Force (USPSTF) list when the code has an A (USPSTF recommends the service and the benefit is likely to be substantial) or B (USPSTF recommends this service and the benefit could be moderate or substantial) designation. Some of your payers will deny the claim if the service isn’t on the USPSTF list.

Pointer: When a procedure’s code description says it’s a screening service, such as with CPT® code 82270 (Blood, occult, by peroxidase activity [eg, guaiac], qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening [ie, patient was provided three cards or single triple card for consecutive collection]) for the high-risk cancer screening, there is no need for modifier 33.

Look to Modifier 33 for Both Therapeutic, Non-Therapeutic Procedures

“Procedures performed for preventative service may or may not result in a therapeutic maneuver like removing a polyp. In both cases, you would use modifier 33 on the appropriate CPT® code to have the claim processed with no co-pay or deductible on the base preventative service as provided in the Accountable Care Act,” informs Michael Weinstein, MD, Vice President of Capital Digestive Care.

Bypass 33 With Medicare Claims

You shouldn’t use modifier 33 on your Medicare claims because under most circumstances, Medicare does not recognize this modifier. For example WPS Medicare does not recognize 33. A Q&A can be found at www.wpsmedicare.com/j8macpartb/resources/provider_types/awv-faq.shtml.

Problem: Medicare will return some claims you submit with modifier 33 with a denial code indicating that the claim contains incomplete and/or invalid information that is not able to be processed.

Good news: Congress legislates CMS coverage for some preventive services but some of these services, have their own “G” codes such as G0105 (Colorectal cancer screening; colonoscopy on individual at high risk), so you don’t need to attach modifier 33.

Pay Attention to Payers Who Provide 33 Guidance

While Medicare won’t pay for claims with modifier 33, some private payers might allow you to bill with that modifier. You’ll find that some private payers publish their guidance and some do not.

Take a look at a few examples of payers’ policies and their criteria for accepting modifier 33.

Tufts Health Plan: This payer accepts and recognizes modifier 33 when you use it with services on the USPSTF list.

MVP: MVP recognizes modifier 33 and takes advantage of its use to accurately report the preventive care services physicians provide to their members, back to CMS.

UnitedHealthcare: This payer’s guidance states that reporting modifier 33 is allowed but they don’t use it to determine preventive care benefits for their members. They refer to their table of procedure and diagnosis codes and claims edit criteria when making decisions on whether preventive care benefits apply.

Cigna: Cigna is on board with modifier 33 but their use of it relies on the claim including diagnosis and procedure codes distinctly for preventive care.

Neighborhood Health Plan: This payer also recognizes and provides guidance for the use of modifier 33. They require you to attach it to CPT®/HCPCS codes included in the USPSTF list which have a category A or B rating. They also refer you to their preventive services provider payment guideline for a list of services and codes at www.nhp.org/provider/paymentguidelines/Preventive_Services.pdf.

What About That Other Modifier ‘PT’?

There’s another modifier that we can’t ignore. “In instances in which a screening procedure on a Medicare patient has turned diagnostic, the modifier PT would be appended to the diagnostic procedure code that is reported (instead of using the screening code G0121 or G0105). 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,” explains Weinstein.

“For example, a colonoscopy that starts out as a screening (that is, G0121, G0105) but turns into a diagnostic procedure (that is, 45385, 45384) then that should be coded with the diagnostic CPT® code with modifier PT to show that it started out as screening,” adds Weinstein.