8 Tips Give You Straight Facts on Modifier 33
Weed through the guidance to properly append this commonly confused modifier.
By G.J. Verhovshek, MA, CPC, and Rita Von Holtum, CPC-H
Nearly 18 months since its introduction at the American Medical Association’s (AMA’s) 2010 CPT® Symposium, modifier 33 Preventive service continues to cause confusion. Here, we review eight quick tips that teach you when and how to append modifier 33.
1. Know Where to Find Information
The AMA published guidance for applying modifier 33 in the December 2010 CPT® Assistant, and followed up with brief entries in CPT® 2012 Changes: An Insider’s View and “Appendix A —Modifiers” of the CPT® 2012 manual. Private payers have also begun to issue guidance on modifier 33 (Search the Web to see if your payer does.).
As CPT® Assistant explains, modifier 33 was created in response to the Patient Protection and Affordable Care Act (PPACA), which requires all health care insurers to cover certain preventive services and immunizations without cost sharing. In other words, insurers must waive the co-pay and deductible and pay, in full, for specified covered services. By appending modifier 33, the provider alerts the insurer that a covered preventive service was provided, and that patient cost sharing does not apply.
2. Know Which Services Are Covered
Only select preventive services and immunizations are fully covered under PPACA. You may append modifier 33 to identify preventive services that fall into the following four categories, per AMA instructions:
1. Services rated “A” or “B” by the U.S. Preventive Services Task Force (USPSTF). Services with an “A” rating have been judged to have a high certainty that the net benefit is substantial. Services with a “B” rating have been judged to have a high certainty of moderate to substantial net benefit. A listing of these services is updated and posted annually on the Agency for Healthcare Research and Quality’s website.
2. 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 (HRSA).
3. Preventive care and screenings provided for women (not included in the USPSTF recommendations) in the comprehensive guidelines supported by HRSA. Examples falling into the categories above include HIV screening in adults and adolescents at an increased risk for HIV infection, bacteriuria screening for pregnant women, blood pressure screening in adults, and colorectal cancer screening in adults beginning at age 50.
4. 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. Examples include Zostavax immunization in adults; inactivated polivirus for children; and hepatitis A and B, human papillomavirus, measles, mumps, and rubella, and influenza for both adults and children.
Nearly five dozen preventive screening and immunization services are covered under PPACA, and may be reported with modifier 33. When reporting a claim with modifier 33, medical records are not required, but must be available upon request.
3. Apply Modifier 33 for Private Payers Only
The Centers for Medicare & Medicaid Services (CMS) has not issued any guidance for modifier 33. There’s a good reason for this: Medicare and Medicaid do not recognize modifier 33.
Claims submitted to Medicare containing modifier 33 will be returned with Medicare Outpatient Adjudication (MOA) code MA130, which indicates that the claim contains incomplete and/or invalid information that is “unprocessable.” As such, you should only append modifier 33 for non-Medicare payers, as per AMA instructions.
Medicare is not exempt from the requirements of PPACA, and must pay in full for covered services; however, Medicare requires the use of dedicated G codes that specifically describe covered services as preventive (e.g., G0202 Screening mammography, producing direct digital image, bilateral, all views). A guide to Medicare-covered preventive services may be found on the Medicare website.
4. Turn to 33 for Screening Turned Diagnostic
You may also apply modifier 33 when a preventive service must be converted to a therapeutic service. “The most notable example of this,” according to CPT® Assistant, “is screening colonoscopy [45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)] that results in a polypectomy [e.g., 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique].”
Reminder: Apply modifier 33 only for commercial carriers. Medicare does not accept modifier 33. If a screening colonoscopy leads to polyp removal for a Medicare patient, report the appropriate removal code (e.g., 45383) with modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure—rather than modifier 33—appended.
5. Selected Services Covered In-network Only
Insurers are permitted to require cost sharing for those services that are not covered under PPACA. Insurers also are permitted to impose cost sharing—or choose not to provide coverage—for recommended preventive services provided out-of-network. Treatment resulting from a preventive screening is subject to cost-sharing if it is not a recommended preventive service.
6. Apply 33 to All Eligible Services
If a physician provides multiple preventive medical services to the same (non-Medicare) patient on the same day, append modifier 33 to the codes describing each preventive service rendered on that day.
7. Cost Sharing Doesn’t Apply for Separate, Same-day Services
The insurer may not impose cost sharing if the primary reason for an office visit is to receive a preventive service; however, per the AMA, cost-sharing is allowed for an office visit if the office visit and covered preventive service are billed separately, and the primary purpose of the office visit is not to deliver the covered preventive service. To illustrate, CPT® Assistant provides the following examples:
- “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.”
8. Designated Preventive Services Don’t Require 33
Do not append modifier 33 for “separately reported services specifically identified as preventive,” per CPT® Appendix A. Included in this category are any HCPCS Level II G codes for preventive services, such as G0202 (screening mammography), G0103 Prostate cancer screening; prostate specific antigen test (PSA), and G0389 Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening. Use HCPCS Level II codes to describe services provided for Medicare and Medicaid beneficiaries. Use CPT® codes, when applicable, to report services for patients covered by private insurance.
For example, to report a covered screening mammography for a non-Medicare patient, you would report 77057 Screening mammography, bilateral (2-view film study of each breast). Modifier 33 is not required because 77057 is a designated screening service. To report the same service for a Medicare patient, report G0202. Modifier 33 is neither required nor accepted by Medicare.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
Rita Von Holtum, CPC-H, lead coder at Sanford Health, has been working in health care for 33 years. Working for a smaller facility, she has worn many hats including coding ED, outpatient, ambulatory surgery, and inpatient accounts. In 2001, she became a certified coder with AAPC. Rita is on the facility Compliance Committee, where her departments work with the Corporate Compliance department on changes and concerns. She mentors new and fellow coders.