Modifier 33 Arrives Quietly But Packs a Punch

Use this new CPT^® modifier to help payers identify preventive services.

Modifier 33, effective since Jan. 1, 2011, slipped through the door quietly and unnoticed, like a neighbor’s cat. The new modifier is not in the CPT® 2011 Professional Edition book, but was announced at the American Medical Association’s (AMA) CPT® Symposium last November, after the CPT® manual had been published. Officially, the modifier’s language is:
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.

Part of Health Reform

Modifier 33 supports a major part of the Patient Protection and Affordable Care Act (Affordable Care Act, or ACA), which requires health care insurers (including commercial insurers) to cover certain preventive services and immunizations without passing the cost on to the provider or patient. Specifically, the AMA’s CPT® Assistant (December 2010, vol. 10, 12) instructs payers not to impose cost sharing on an office visit if the primary reason for the visit is to receive preventive services. Cost sharing is permitted for an office visit when it is billed separately from the covered preventive services, and the primary purpose of the office visit is not preventive. Payers also may impose cost sharing (or choose not to provide coverage) if the provider is out-of-network, or for services not included in the law.
Modifier 33 allows a provider to identify a service as preventive under ACA, and to indicate that cost sharing does not apply. You may append the modifier to CPT® or HCPCS Level II codes when:

• The primary reason for the visit was preventive, and you wish to mark the service as preventive so payer processing systems will notice it as such.
• The primary visit was preventive, but resulted in a therapeutic service, such as when a 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) or G0104 Colorectal cancer screening; flexible sigmoidoscopy) becomes a polypectomy (45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyps, or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).
• Multiple preventive services are provided the same day, and you wish to identify each preventive service that day.

You needn’t append modifier 33 for inherently preventive services; for example: a screening mammography (77057 Screening mammography, bilateral (2-view film study of each breast)), screening colonoscopy (45378 or G0104), or prostate screening with prostate specific antigen test (PSA) (G0103 Prostate cancer screening; prostate specific antigen test (PSA)). If the code description says “screening,” that’s a pretty good indication you don’t need modifier 33. Inherently preventive services also include immunizations for routine use in children, adolescents, and adults, as recognized by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). One example of such an immunization is the measles, mumps, and rubella (MMR) shot (90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use).
Payers may implement this policy as new coverage is established, or as existing coverage is renewed. A review of payers’ policy announcements indicates they are accepting modifier 33. The first indication of federal implementation came in March, when version 12.1 of the integrated Outpatient Code Editor (I/OCE) included the addition of an edit that acknowledges modifier 33. Providers and payers use the I/OCE application to manage the billing of outpatient prospective payment system (OPPS) services. Outpatient hospital services and ambulatory surgical centers (ASC) use OPPS, billing through CPT® and HCPCS Level II ambulatory patient categories (APCs).

Modifiers 33 and PT

Modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure also is new for 2011. When a patient is scheduled for a G0104, G0105 Colorectal cancer screening; colonoscopy on individual at high risk, or G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk, but a positive finding changes the procedure to a diagnostic colposcopy, Medicare will waive the patient deductible for the diagnostic colonoscopy performed on the same day as a scheduled screening colonoscopy. However, patients are responsible for the copay for the diagnostic colonoscopy.

What Qualifies?

Expected confusion about modifier 33 prompted the AMA and CMS to outline when it can be used. The new modifier is applicable for identifying preventive services without cost sharing in four categories:

• Services rated “A” or “B” by the U.S. Preventive Services Task Force (USPSTF) as posted annually on the Agency for Healthcare Research and Quality’s website.
• Immunizations for routine use in children, adolescents, and adults as recommended by the ACIP of the CDC
• 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
• Preventive care and screenings provided for women (not included in the USPSTF 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 graded with an “A” rating have been judged to have a high certainty of a substantial net benefit. Services graded with a “B” rating have been judged to have a high certainty of moderate to substantial net benefit.
For more information about modifier 33, contact your payer. Remember that implementation will differ for your patients as their health plans renew.

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