Pediatric Coding Alert

This modifier could ensure that your preventive claims don’t sink.

Since your pediatric practices most likely see patients for preventive services every day, you need to know the ins and outs of modifier 33. Check out the following Dos and Don’ts to ensure that you keep your screening pay rolling into your account.

Watch for Descriptors That Say ‘Screening’

You’ll use modifier 33 (Preventive services) to communicate to your payer that your pediatrician performed a preventive service, such as a visual acuity screening in children, and that the patient’s co-insurance, co-payment, and deductible for the applicable services should be waived.

It’s key for the pediatrician to communicate with the biller and indicate when the service is being performed for preventive purposes as opposed to diagnostic or treatment purposes.

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. You can download the entire list at www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/.

Appreciate the Payers Who Provide 33 Guidance

Medicare does not typically recognize modifier 33, so some Medicaid payers may follow suit, but many private payers allow you to bill the 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 back to CMS the preventive care services physicians provide to their members.

United Healthcare: 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 that apply.