Clear Up Colonoscopy Modifier Confusion

Sort through the guidance to master use of modifiers PT and 33.

By Anna Conlon Barnes, CPC, CEMC, CGSCS

When it comes to colonoscopy coding, I keep Medicare rules clear of any commercial payer rules. In our coding department, any patient undergoing a colonoscopy for screening or surveillance with no current symptoms gets either modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure or modifier 33 Preventive services appended, depending on the payer. This shows the patient did not start out as a symptomatic, diagnostic procedure, but as a non-symptomatic screening or surveillance.

Resource tip: For more information on screening vs. surveillance colonoscopy, see “Colonoscopy: Screening or Surveillance?” (March 2013 AAPC Cutting Edge, pages 20-24), available online.

Medicare Guidelines

For all of our Cahaba GBA Medicare Part B claims that originate as a screening or surveillance and result in a therapeutic procedure (e.g., polypectomy), we report the appropriate CPT® code with modifier PT for patients either at low-risk (e.g., a principal diagnosis of V76.51 Special screening for malignant neoplasms of colon) or high-risk (e.g., a principal diagnosis of V12.72 Personal history of colonic polyps).

Example

A Medicare patient with a personal history of polyps presents for a surveillance colonoscopy. A polyp is found and snared. This is reported 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, with modifier PT appended and a primary diagnosis of V12.72. The appropriate diagnosis for the procedure (i.e. polyp removal) is reported as secondary, and is referenced with a “2” in box 24E of the CMS 1500 claim form.

Sources: MLN Network “Quick Reference Information: Preventive Services” and MLN Matters® Number: MM7012 Revised

Note that the Centers for Medicare & Medicaid Services (CMS) does not differentiate between screening and surveillance colonoscopy, as do many commercial carriers. Medicare treats surveillance as a high-risk “screening” rather than a diagnostic service; this prevents the patient from having out-of-pocket expenses.

Source: CMS Transmittal 864

Commercial Guidelines

For Blue Cross and Blue Shield of Georgia (BCBSGA) claims, my practice uses the appropriate CPT® colonoscopy code with modifier PT for both screening and surveillance colonoscopies that result in therapeutic procedures. But for other commercial carriers (e.g., Cigna), we append modifier 33 to the appropriate CPT® colonoscopy code for screening and surveillance colonoscopies that result in therapeutic procedures.

Source: BCBSGA and Cigna guidelines

Unlike Medicare, commercial carriers frequently differentiate between screening colonoscopy (no personal history of colonic polyps) and surveillance colonoscopy (personal history of colonic polyps). These payers follow the U.S. Preventive Services Task Force (USPSTF) statement, “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.”

Source: USPSTF, “Screening for Colorectal Cancer: Clinical Summary of U.S. Preventive Services Task Force Recommendation

I have seen some carrier edits look only to the primary diagnosis code when determining benefit (ignoring modifier 33), which may lead to an out-of-pocket expense for the patient. I have also witnessed carriers accept modifier 33 and V12.72 in the primary diagnosis position, and process the service as a screening benefit with no out-of-pocket expense. It all depends on the carrier policy and edit, so always consult your individual payers’ policies for instruction.

Do not confuse the issue of assigning ICD-9-CM codes to describe screening versus surveillance (diagnostic) colonoscopy with the issue of when to report modifier PT versus modifier 33. I report the diagnosis according to the ICD-9-CM code and carrier regulations. I then determine whether to add modifier PT or 33 based on if the patient started out as a screening/surveillance or had the symptoms/conditions as the ordering diagnosis.


 

Anna Conlon Barnes, CPC, CEMC, CGSCS, is the director of operations for Atlanta Colon and Rectal Surgery. Her job duties include overseeing corporate compliance programs, physician auditing and education, director of information technology, as well as managing billing department activities, including staff coding compliance and education. Barnes holds a BSED from the University of Georgia, and has 18 years of experience in the business of colon and rectal surgery. She is a member of the Atlanta Perimeter, Ga., local chapter.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 427 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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