Wiki Modifiers -PT and -33

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bridgettemartin

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Just when you think you have it all figured out...

We have been using these modifiers for some time now to indicate a screening colon turned diagnostic. We are now questioning whether or not these modifiers should have been used when a high risk patient returns for a recall colonoscopy and the procedure becomes therapeutic.
Are you using these modifiers with primary dx codes of V12.72, V16.0, V10.05 etc? Or are you only appending the modifier for average risk screening colons that become therapeutic?
I have searched and searched and can't find anything in writing that tells me one way or the other.

Thanks!
Bridgette Martin LPN, CPC, CGIC
 
High risk indicators should be documented as a routine screening for said history aand billed as a screening for said histori i.e. V76.51, v12.72.

The modifiers Pt and 33 are only to indicate when a procedure became diagnostic due to findings such as a polyp. Pt is only for medicare and their guidelines are currently very messy for it's use. Currently we have found the only carrier accepting the 33 modifier for it's specified use is Anthem.

Hope this helps. :D
 
The 33 modifier is not used to just indicate when a screening turns diagnostic. The 33 modifier is to be used for preventitive services regardless.
 
Legislation has not addressed the issue of a patient with a history of polyps and a followup colonoscopy. These patient are coming back sooner that 10 years if it was screening in the first place. I would use the cpt code 453__ whatever the therapeutic procedure is and would not use a 33 or PT and I would use the V12.72 prime with the other diagnosis secondary. These ins co know when a patient has a Hx of polyps and to bill it as a regular screening would be fraudulent I believe.
 
sbarrila said:
The 33 modifier is not used to just indicate when a screening turns diagnostic. The 33 modifier is to be used for preventitive services regardless.
Click to expand...

Can you expand on this comment and provide links or information to where you found this?

Thanks
 
We have been billing our repeat colons as 453.. and using V12.72 as the dx. We just found out yesterday that our hospital is billing these as screenings and of course they are being denied by the insurance company due to the fact that the patient just had a screening within the last 2 years. The hospital is telling us that they have new guidelines to go by and they have to bill them this way. She faxed me those guidelines but I don't think they are guidelines. They were from an article in HCPro/just coding. Do you know of any other articles in the coding world addressing this issue?
 
screening vs diagnostic

Either of the screening codes- G0105 or G0121 can turn into a diagnostic procedure if polyps are found, so the PT modifier would be used regardless of whether the patient was high or low risk at the beginning of the procedure. If you have patients who are not high risk based on the list of allowable diagnosis codes and who are returning before their next payable screening, I would ask what reason the physician has for doing it "early". If there is a medical reason- rectal bleeding, abdominal pain, etc., then it would not be a screening and would not be subject to the waiting period.

This is from Medicare Learning Network:
The Medicare policy is that the deductible is waived for all surgical procedures (CPT code range of 10000 to 69999) furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services. Modifier PT has been created and providers and practitioners should append the modifier to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening sigmoidoscopy HCPCS code. The claims processing system would respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test.
Here is a link to WPS Medicare's modifier PT fact sheet:
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/pt_modifier.shtml

I think the biggest cause of all our confusion is due to the fact that the payers did not have the modifiers loaded in their systems in January as required. As a result, we've received so many denials on correctly coded and billed claims that we were unsure of how to proceed.
 
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We don't have any issues using the PT or -33 modifiers. Our claims are being paid. The problem is the patients are coming back for a repeat colonoscopy due to the history of polyps within the screening benefit period. The patient doesn't have any issues other than the history of polyps. We do bill as diagnostic with V12.72 and they are getting paid. The facility where the procedures are being performed are billing them as screening. We don't feel these are screening but we can't get the hospital to budge on their "new" policy. We are looking for any information that states they have to be billed as a screening and not diagnostic. So far, we can't find anything to back their new policy up.
 
"These ins co know when a patient has a Hx of polyps and to bill it as a regular screening would be fraudulent I believe. "
Willette -
I have spoken with the AGA, and that is incorrect. If a patient is having a colonoscopy because of a hx of polyps, and he/she has no other symptoms, then it is a screening colonoscopy and the V76.51 along with V12.72 should be billed. The reasoning is this - polyps can be come cancerous. So if you are doing a screening colonoscopy because of a personal history of polyps, then you are doing it to see if the patient has developed cancer because of their history of having polyps. Therefore the V76.51 is appropriate, and would not be fraudulent.

I have never used the modifer -33, can someone clariify when it should be used?
 
Mod 33 should be used on all patients except Medicare patients (Medicare patients use the PT ONLY if a biopsy or snare was done. If no biopsy is done then you would use the "G" code without the PT modifier). If a patient comes in for a screening it doesn't matter if they have a biopsy or not, you are supposed to append the modifier 33 to all codes. Example - If the pt had a biopsy in the ascending colon and a snare in the descending colon you would put the modifier 33 on both codes (in addition to any other modifier you would normally append). If they did not have a biopsy you would only append the mod 33 to the 45378. The 33 is more of an indicator code, it indicates that the patient came in for a screening. That is the way I see it and that is the way I have been using the code. I hope this helps. :)
 
Mary Shults LPN-CPC

sbarrila said:
The 33 modifier is not used to just indicate when a screening turns diagnostic. The 33 modifier is to be used for preventitive services regardless.
Click to expand...
This is the correct application of the 33 modifier. It is intended to be used for preventative even if the procedure does not turn into a diagnostic one. This is the CPT definition of the modifier.
 
DEDGE CGIC said:
High risk indicators should be documented as a routine screening for said history aand billed as a screening for said histori i.e. V76.51, v12.72.

The modifiers Pt and 33 are only to indicate when a procedure became diagnostic due to findings such as a polyp. Pt is only for medicare and their guidelines are currently very messy for it's use. Currently we have found the only carrier accepting the 33 modifier for it's specified use is Anthem.

Hope this helps. :D
Click to expand...


If the pt is medicare HMO than we also have to bill with 33 modifier????
 
DEDGE CGIC said:
High risk indicators should be documented as a routine screening for said history aand billed as a screening for said histori i.e. V76.51, v12.72.

The modifiers Pt and 33 are only to indicate when a procedure became diagnostic due to findings such as a polyp. Pt is only for medicare and their guidelines are currently very messy for it's use. Currently we have found the only carrier accepting the 33 modifier for it's specified use is Anthem.

Hope this helps. :D
Click to expand...

Can we use modifier PT on commercial or Medicaid ? thx
 
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