August 01, 2016
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
The American Medical Association (AMA) introduced CPT® modifier 33 Preventive service in response to the Affordable Care Act (ACA), which requires health care insurers to cover, in full, specified preventive services and immunizations. When appended to a CPT® code describing a preventive service, modifier 33 alerts the insurer that the service is covered and payable under the ACA.
Here are the essential facts to apply modifier 33 with success.
Append 33 for private payors only
Medicare payors do not recognize modifier 33, and will not reimburse claims submitted with the modifier. Medicare requires the use of dedicated G codes to describe covered preventive services (e.g., G0202 Screening mammography, producing direct digital image, bilateral, all views). A guide to Medicare-covered preventive services may be found on the Medicare website.
Services may be covered in-network only
AMA’s CPT Assistant (December 2010) explains that insurers may require cost sharing for those services that are not covered under ACA. Insurers also are permitted to impose cost sharing—or choose not to provide coverage—for recommended preventive services that are provided out-of-network. Lastly, treatments resulting from a preventive screening are subject to cost-sharing if the treatment is not itself a recommended preventive service.
Append 33 to all eligible services
If a provider provides multiple preventive medicine services to the same patient on the same day, append modifier 33 to the codes describing each preventive service rendered.
Don’t use 33 for designated preventive services
Do not append modifier 33 for “separately reported services specifically identified as preventive,” per CPT® Appendix A. For example, 77057 Screening mammography, bilateral (2-view film study of each breast) is a designated screening service. Similarly, do not append modifier 33 to HCPCS G codes describing preventive services provided to Medicare beneficiaries, such as G0103 Prostate cancer screening; prostate specific antigen test (PSA) or G0389 Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening.
Office visits aren’t usually separately reimbursed
If a covered preventive service is part of an office visit, the insurer may not impose cost sharing if the primary reason for the visit is to receive preventive services; however, per AMA, cost-sharing is allowed for an office visit if the office visit and covered preventive services are billed separately, and the primary purpose of the office visit is not to deliver the covered preventive services. To illustrate, CPT Assistant (December 2010) provides the following examples:
- A 45-year-old male individual receives a cholesterol screening test, which is a recommended preventive service, during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services.
- An individual receives a recommended preventive service that is not billed as a separate charge. The primary purpose for the office visit is a recurring abdominal pain and not the delivery of a recommended preventive service. Therefore, the plan or issuer may impose cost-sharing requirements for the office visit.
- An individual receives a recommended preventive service that is not billed as a separate charge, i.e., it is part of the office visit and the delivery of said service is the primary purpose of the office visit. Therefore, the plan or issuer may not impose cost-sharing requirements for the office visit.
33 may also apply to screening turned diagnostic
You may also apply modifier 33 when a preventive service must be converted to a therapeutic service. Per CPT Assistant (December 2010), “The most notable example of this is 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)] that results in a polypectomy [e.g., 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique].”
Note that the above example applies only to payers who adhere to AMA guidelines. Medicare specifies different guidance if a screening colonoscopy leads to polyp removal, which can be found in MLN Matters Number SE0746, available on the CMS website.
Have your documentation ready
Medical records are not required when reporting a claim with modifier 33, but must be available upon request.