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Modifier 33 - CPT Symposium

  1. Default
    Exam Training Packages
    I need to correct that. It's beginning to seem that 33 is for E&M and PT is for surgical procedures.
    PT is a modifier specifically for this purpose:
    In the final rule, CMS created for Medicare a new Healthcare Common Procedure Coding System (HCPCS)modifier-PT (CRC screening test, converted to diagnostic test or other procedure) to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code, or as a result of the barium enema when the screening test becomes a diagnostic service. 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. Coinsurance for Medicare beneficiaries would continue to apply to the diagnostic test and to other services furnished in connection with, as a result of, and in the same clinical encounter as the screening test.

  2. #22
    Madison Area Chapter in Madison WI
    There is a fair amount of confusion on the intended use of Modifiers 33 and PT.

    I’ll talk about Modifier 33 first. The short answer to when you are to use Modifier 33 is on "preventive services". The long answer is in Michellde's post from 1-3-11. I've included an excerpt at the bottom of this page.

    Insurance carriers have known about this for awhile because they had to identify preventive services that were included in the mandate. I have worked with a group of carriers to identify how they were going to do that. My experience is that carriers have identified these services by CPT, HCPCS, and/or ICD codes or a combination of these. So they don't "need" the Modifier 33 to identify preventive services that have no cost sharing.
    From a coding perspective, we should use Modifier 33 when applicable.

    OK - now Modifier PT. First, although Modifiers 33 and PT seem to be connected, they identify different things. Stick with me here.

    Modifier 33 identifies screening/preventive services. Modifier PT is used to identify when a "screening/preventive" services turns into a diagnostic/theraputic service.

    The most common example for Modifier PT would be when a person has a screening colonoscopy and a polyp is found. If the polyp is removed, the "screening" turns into a therapeutic procedure. In this situation, Modifier PT is used to identify that the procedure started as a screening but ended up a therapeutic procedure. Medicare will waive the deductible in this situation. This is not part of the USPSTF mandate.

    CPT modifier 33 is applicable for the identification of preventive services without cost-sharing in these four categories:

    1.Services rated “A” or “B” by the US Preventive Services Task Force (USPSTF) (see Table 1) as posted annually on the Agency for Healthcare Research and Quality’s Web site: http://www.uspreventiveservicestaskf...spsabrecs.htm;

    2.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;

    3.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; and

    4.Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration.

    US Preventive Services Task Force. USPSTF A and B Recommendations. August 2010. Available at: http://www.uspreventiveservicestaskf...uspsabrecs.htm.
    Happy Coding, Claudia

    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email] - website

  3. Default Modifier 33
    45378 is a diagnostic colonoscopy so 33 does not belone appended - even if it was in the AMA example. A test does not go from diagnostic to screening. If they used the G code for screening colonoscopy, and a polepectomy followed, it seems to me that 33 is appended to the polepectomy because it was the result of a screening service? Very confusing. I looked at some of the CPT F codes that might work such as 4158F 'patient counseled about risks of alcohol abuse' because it meets an A criteria but still not positive. Anyone esle have any ideas?

  4. Default Modifier 33
    More on modifier 33. But still unclear: I do not think payers want therapeutic services to be co pay free. Main problem is that the preventative services on the PPACA list do not have codes. Any E/M services that also includes screening could possible use modifier 33?

    There is a new modifier in town, and its number is 33. Because of the Patient Protection and Affordable Care Act (PPACA), there is now a requirement for health insurance plans to cover preventive services without any cost sharing (meaning no copays, coinsurance or deductibles applying).

    What constitutes a preventive service as defined by the PPACA? Services that the US Preventive Services Task Force (USPSTF) deems a grade A (defined as “high certainty that the net benefit is substantial”) and grade B (defined as “high certainty that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial”). The list of grade A and B recommendations can be found on the USPSTF website at: http://www.uspreventiveservicestaskf...uspsabrecs.htm Modifier 33 should be applied to any of these services when they are provided.

    The December 2010 CPT Assistant contains an article that lists the USPSTF A and B recommendations. The article also highlights an interesting situation, when a screening colonoscopy results in a polypectomy. Because the service that was initiated was a preventive service, the recommendation of the article is to use a 33 modifier on the CPT code for the polypectomy. This also would apply to any other service that was initiated as a preventive service but becomes a therapeutic service.

    Remember CPT Assistant is available for Audit & Revenue Resource Center users and Coding and Revenue Resource Center users. Look for the link in the Hot Resources section on the main page.

  5. Question Modifier 33
    I was told this modifier was not to be used in the ASC. I'm not certain that is correct. It's not listed as a modifier that is to beused in the ASC in the CPT but then it's not listed in the CPT all. I've read the updated release from the AMA but it doesn't specifically state use in the ASC is allowed.

  6. #26
    My biggest confusion with this modifier is regarding screening turned diagnostic colonoscopies. The May issue of Coding Edge included an article "Modifier 33 Arrives Quietly But Packs a Punch." This piece stated that PT is to be used for Medicare, 33 is for commericial payers. I have recently began using 33 for non-Medicare colonoscopy claims. These are performed in an ASC and so far I have not had a problem.
    Shannon, CPC, CCA

  7. Default Modifier 33
    When it is stating (cost sharting) is that the same as split billing?
    Would like more clarification on this cost sharing factor, please!

    thank you
    Lavonne H

  8. #28
    Default Modifier 33
    I have had numerous inquiries about this modifier when I introduced it at our CPT Update workshop. I have not found any carriers including Medicare that are recognizing this modifier. I have told my clinics that until more information comes forth to not use this modifier to eliminate the denials for not valid modifier. I am in Louisiana and our carrier is even denying it. Lynn Kimsey, CPC, CPMA, CPC-I, CEMC

  9. #29
    Newport News, VA
    Default Modifier 33
    CMS does not recognize this modifier, although Anthem Products do. From how I understand it the note must specifically state that the is screening for high blood pressure (ex V81.1 or V17.49) the record cannot just show generalized screening code V70.0. If anyone can find any information to either confirm or prove this wrong, please let me know. Thanks

    I stand corrected. I just found an update on the CMS website.Pub 100-04 Medicare Claims Processing Transmittal#2172 Change Request#7344 Appendix M the effective date is 01/01/11 to add modifier 33 to the valid modifier list list. Pub 100-20 One-Time Notification Transmittal#864 gives a list of which Preventative Services with the CPT® Codes will waive/not waive the patient's portion.
    Last edited by Eagle Eye; 06-24-2011 at 12:04 PM. Reason: updated information
    Eagle Eye

  10. Default Modifier 33 article
    In reply to whether or not modifier 33 should be used for E/M, I found this article, which says the answer is "YES". However, I feel that since each insurance company has limitations on how often a patient can receive a screening that appending this modifier should be reserved for the procedure, rather than the pre-procedural visit, as I don't think they'll wave the coins for both and the procedure would obviously be more costly.

    Please see below:

    --- Article Information ---
    This article was printed from Codapedia™ - The collaborative online encyclopedia for medical coding and reimbursement.
    Article's URL:

    Modifier 33 and Modifier PT
    how and when to use these modifiers
    By: Codapedia Editor (Fri, Mar/02/2012)

    In 2011, both CPT® and CMS developed a new modifier in response to provisions of the Affordable Care Act (ACA) passed in 2010. The modifier was developed late enough in 2010 that it wasn't included in the 2011 CPT® book, although it was a valid modifier for that year. The ACA mandated that any service that received an A or B rating from the US Preventive Services Task Force (USPSTF) be paid without co-pay or deductible for Medicare patients. Also, any group insurance plans that renewed or started after September 2010 that did not claim “grandfathered” status must also include first dollar coverage for services which the USPTF graded as A or B. According to the AMA document on modifier 33, when providing these A or B rated services are “part of an office visit, the office visit may not have cost-sharing if the primary reason for the visit is to receive preventive services.”

    The USPSTF is a function of the Department of Health and Human Services. According to their statement, “The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."” The USPSTF reviews scientific literature and then makes recommendations for screening services. You can find a list of their current recommendations on their website at


    Modifier 33, Preventive Service: When the primary purpose of the service is the delivery of an evidenced-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 Services, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.

    Use modifier 33 on the preventive medicine service/office visit and on any of the screening tests identified on the list from the USPSTF. This tells the payer that these are preventive services, and should prevent the payer from assessing a co-pay or deductible. The patient will have full coverage. Use a diagnosis code for the examination, such as V70.0, V20.2, or V72.31.

    Practices should still verify coverage and benefits prior to the visit.

    Modifier PT is a HCPCS modifier intended to be used when a scheduled colorectal screening test becomes a therapeutic or diagnostic service. Why would this be needed? Because a screening test has first dollar coverage and a therapeutic or diagnostic test will be subject to co-pay or deductible. Medicare instructs medical practices to use HCPCS codes for colorectal screening (for example, G0105, among others.) But if an abnormality is found and a biopsy is taken or a polyp removed, the surgeon uses a CPT® code in the family of codes starting with 37…. In that case, use the CPT® code, append modifier PT to the service and the patient will not be charged a co-pay or deductible. CMS's quick reference guide to preventive services states, “No deductible 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 should be appended to at least one CPT® code in the surgical range of 10000 to 69999 on a claim for services furnished in this scenario.

    --- end ---

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