Wiki Modifier 33 - better instruction

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Medicare and replacement plans don't recognize modifier-33. They created modifier PT to be appended to a preventative service that becomes therapeutic.
For instance, an average risk screening colon that resulted in a snare polypectomy would be submitted with 45385-PT/V76.51; (insert polyp code).
PT modifier is not to be used when submitting a code that is inherently screening, such as G0121. That code is a screening code to begin with, whereas a plain old colonoscopy code of 45378 is not.
So, for a commercial plan that does not accept G-codes, if the patient had an average risk screening colonoscopy, and no polyps were found, you would submit 45378-33/V76.51.
Some plans (many self-funded plans) are grandfathered in, for now, and do not have to abide by the ruling. Their system edits may accept modifer-33, but that doesn't mean they'll cover it at 100%. Again..for now. More and more grandfathered plans are up for renewing and once they do that, they are required to follow the mandate.
 
It was my understanding that you would put a Modifier 33 on if it was for a preventative service. We have been struggling to find information on when an insurance identifies it as preventative if there is a history of polyp or personal history of colon cancer. For example, UHC does not list V10.05 or V12.72 as a preventative diagnosis. Cigna is the same way from the information that I have. Per AAPC May 2013 article it states to append modifier 33 whether a therapeutic procedure was performed or not. This is because 45378 is inherently a screening procedure. I am unable to find guidelines for most insurance companies on if they want the 33 modifier or not. In General do you put the 33 modifier on there when they have V12.72 or V10.05 or would you follow the same guidelines UHC and Cigna have out there? Per a recent General Supercoder article t it states that 33 modifier should be used if patient is coming in because of V10.05following compliance with the Affordable Care Act. Thoughts adive?? Thanks!:confused:
 
We also, have had trouble finding definitive information regarding whether or not personal history codes can/should be used with modifier-33. The ACA doesn't specifically address surveillance procedures. The problem with that, is that it is then left up to each insurance company to determine if they consider surveillance colonoscopies under the screening mandate. This can be a very hot topic for coders, and there are very valid arguments on both sides of the coin. I have been coding GI for 5 years, and the screening vs surveillance debate was going on then.
I look at it like this. Medicare states that surveillance colonoscopies are high risk screenings. Note the word screening. medicare has taken it a step further by assessing coinsurance if a screening service converts to a diagnostic service (polyp removal).
After much (and I mean very much) discussion in our office...with billing managers, and providers, we have decided that we will append the -33 modifier for all asymptomatic, preventative colonoscopies. This includes personal hx of polyps. It is up to payer to determine if they will assess coinsurance with v12.72 as primary. Some do, and some do not.
 
Thank you for the information. There seems to be no cut clear answer. Do you also put a -33 on if it is for history of colon cancer V10.05? If I understand you right basically we could put a 33 modifier on there as long as this was asymptomatic and it will be up to the payer on how they process it. Certain payers like i had mentioned we know will not consider it as preventative with V12.72 or V10.05
 
Soms4 said:
Thank you for the information. There seems to be no cut clear answer. Do you also put a -33 on if it is for history of colon cancer V10.05? If I understand you right basically we could put a 33 modifier on there as long as this was asymptomatic and it will be up to the payer on how they process it. Certain payers like i had mentioned we know will not consider it as preventative with V12.72 or V10.05
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If the patient is coming back for their 6mo or 1 year recall after being diagnosed, I don't typically see them being ordered as preventative, so in those cases, no.
However, if a patient had colon cancer 6 years ago and they are recalled every 2 years, they are a high risk screening, so yes.
 
At the first of the year we had about 3 or 4 Blue Cross Texas claims deny, coded as 45378 with dx V12.72, after some research, I found on BC website a Q & A in regards to Colonoscopies dated November 2012, if a pt is coming in about 5 yrs later due to history & nothing else was found, it will be applied to pt cost sharing... Deductible. It is best to get ABNs and Insurance waivers completed & signed :)
 
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