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 adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.
Modifier 33
UnitedHealthcare considers the procedures and diagnostic codes and Preventive Benefit Instructions listed in the table below in determining whether preventive care benefits apply. While modifier 33 may be reported, it is not used in making preventive care benefit determinations.
Definitions Section: Added definition of Modifier 33.
Coding Section:
Added Modifier 33 statement.
Osteoporosis Screening:
o Updated USPSTF ‘B’ rating description to align with January 2011 USPSTF Recommendation Statement.
o Deleted the “C” rating that was part of the previous USPSTF Recommendation Statement.
Screening for Visual Impairment in Children:
o updated USPSTF ‘B’ rating description to align with January 2011 USPSTF Recommendation Statement.
Code Descriptions Updated:
o 82952 and G0437 (Updated descriptions are effective 1/1/11.)
Codes Added:
o Abdominal Aortic Screening: 76700, 76705
o Cervical Cancer Screening: P3000, P3001
o Hepatitis B Screening: 87340, 87341
o HIV Screening: ICD9 diagnosis code V73.89
o Wellness Examinations: 99461, S0610, S0612, S0613
o Behavior Counseling/Healthy Diet: S9470
Codes Deleted:
o Immunizations: 90470 (Code was retro terminated back to 12/31/10.)
o Hepatitis B Screening: 87515, 87516, 87517
o HIV Screening: 87534, 87535, 87536, 87537, 87538, 87539
Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But, MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.
Tips for Billing CPT Modifier 33
The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for nongrandfathered health plans. The appropriate use of modifier 33 reduces claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.
Modifier 33 should be appended to codes represented for services described in the US Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.
The CPT® 2016 Professional Edition manual shares the following information regarding the billing of modifier 33, “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 mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”
Modifier 33
Tufts Health Plan accepts and recognizes the use of modifier 33 when billed with services on the U.S. Preventive Services Task Force List that have an A or B rating.
The American Medical Association created this modifier to allow providers to identify a preventive service for which patient cost sharing does not apply under the Patient Protection and Affordable Care Act, which prohibits patient cost sharing for non-grandfathered plans.
Modifier 33 is appropriate to use with a CPT code that is a diagnostic/treatment service being performed as a preventive service.
Billing Guidelines
Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance. Modifier 33** The appropriate use of modifier 33 will help reduce claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 applies to commercial lines of business only.
** CPT modifier 33 is applicable to preventive services that do not have a unique code for such services (e.g., E&M codes such as, 99401 would not require modifier 33 as this code already indicates a preventive medicine service. However, code 99213
would require modifier 33 when the provider indicates that the service was preventive).
** If multiple preventive medicine services are provided on the same day, then the modifier is appended to the codes for each preventive service rendered on that day.
** Modifier 33 should be used when only preventive services were rendered on that date, not when combined with other non-preventive services.
** CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.
** CPT codes identified as inherently preventive, (e.g., screening mammography) should not be appended with modifier 33.
** This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).
Additional information about modifier 33 is available via the American Medical Association website, http://www.ama-assn.org/ama1/pub/upload/mm/362/new-cpt-modifier-for-preventiveservices. pdf.
Modifier PT ** Modifier PT applies to Medicare products only (Medicare Advantage and Medicare Supplemental). To determine the appropriate use of modifier PT, it’s important to know why the member is presenting for treatment.
Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or other procedure (impacts colonoscopy and sigmoidoscopy codes). The appropriate use of modifier PT will help reduce claim adjustments related to colorectal screenings and your corresponding refunds to members.
Please see the following scenarios for guidance:
** Screening exam only: In a situation where a member presents for treatment solely for the purpose of a screening exam, without any signs or symptoms of a disease, then such a procedure should be considered a screening. The appropriate use of diagnosis codes and screening procedure codes is valuable in promoting appropriate adjudication of the claim. The use of the modifier PT in conjunction with a CPT procedure or HCPCS code that is defined as a screening based on that code’s description is not necessary.
** Treatment due to signs or symptoms to rule out or confirm a suspected diagnosis: In the instance that a member presents for treatment due to signs or symptoms to rule out or confirm a suspected diagnosis, such an encounter should be considered a diagnostic exam, not a screening exam. In such a situation, the modifier PT should not be used and the sign or symptom
should be used to explain the reason for the test.
** Screening colorectal exam converted to a diagnostic service: In a circumstance where a member presents for a screening exam (without signs or symptoms), and an issue is encountered during that preventive exam, then such a circumstance would warrant the use of the PT modifier. The procedure and diagnosis codes that would typically be used in such an instance may not clearly demonstrate that the service began as a screening procedure, but had to be converted to a diagnostic procedure due to a pathologic finding (e.g., polyp, tumor, bleeding) encountered during that preventive exam. The use of the PT modifier in the instance of a screening colorectal exam being converted to a diagnostic service would clarify that despite the end result the service began as a screening service.
Billing Guidelines
Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance. Modifier 33** The appropriate use of modifier 33 will help reduce claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 applies to commercial lines of business only.
** CPT modifier 33 is applicable to preventive services that do not have a unique code for such services (e.g., E&M codes such as, 99401 would not require modifier 33 as this code already indicates a preventive medicine service. However, code 99213
would require modifier 33 when the provider indicates that the service was preventive).
** If multiple preventive medicine services are provided on the same day, then the modifier is appended to the codes for each preventive service rendered on that day.
** Modifier 33 should be used when only preventive services were rendered on that date, not when combined with other non-preventive services.
** CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.
** CPT codes identified as inherently preventive, (e.g., screening mammography) should not be appended with modifier 33.
** This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).
Additional information about modifier 33 is available via the American Medical Association website, http://www.ama-assn.org/ama1/pub/upload/mm/362/new-cpt-modifier-for-preventiveservices. pdf.
Modifier PT ** Modifier PT applies to Medicare products only (Medicare Advantage and Medicare Supplemental). To determine the appropriate use of modifier PT, it’s important to know why the member is presenting for treatment.
Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or other procedure (impacts colonoscopy and sigmoidoscopy codes). The appropriate use of modifier PT will help reduce claim adjustments related to colorectal screenings and your corresponding refunds to members.
Please see the following scenarios for guidance:
** Screening exam only: In a situation where a member presents for treatment solely for the purpose of a screening exam, without any signs or symptoms of a disease, then such a procedure should be considered a screening. The appropriate use of diagnosis codes and screening procedure codes is valuable in promoting appropriate adjudication of the claim. The use of the modifier PT in conjunction with a CPT procedure or HCPCS code that is defined as a screening based on that code’s description is not necessary.
** Treatment due to signs or symptoms to rule out or confirm a suspected diagnosis: In the instance that a member presents for treatment due to signs or symptoms to rule out or confirm a suspected diagnosis, such an encounter should be considered a diagnostic exam, not a screening exam. In such a situation, the modifier PT should not be used and the sign or symptom
should be used to explain the reason for the test.
** Screening colorectal exam converted to a diagnostic service: In a circumstance where a member presents for a screening exam (without signs or symptoms), and an issue is encountered during that preventive exam, then such a circumstance would warrant the use of the PT modifier. The procedure and diagnosis codes that would typically be used in such an instance may not clearly demonstrate that the service began as a screening procedure, but had to be converted to a diagnostic procedure due to a pathologic finding (e.g., polyp, tumor, bleeding) encountered during that preventive exam. The use of the PT modifier in the instance of a screening colorectal exam being converted to a diagnostic service would clarify that despite the end result the service began as a screening service.
