We have different set of codes in medical coding. CPT codes, ICD 10 and Modifiers are the main pillars of Medical coding. If you are good in finding correct code, you will be perfect medical coder. CPT code are responsible for payment of procedures, since each CPT code represent a Procedure or Exam and has as particular dollar value.

But, we can increase or decrease the CPT code dollar value by adding Modifiers to it. Yes, Modifiers affects the reimbursement of the procedure.

Modifier are two digit numerical codes like modifier 57, 58 or 78  etc and should be used only with the CPT codes.

Modifier 32 and 33 are some of these modifiers which are used only when there is a clear documentation for coding these modifiers.

We have already discussed about modifier 22, 23, 24 and 25 previously. Also, you can checkout the list of  modifiers in medical coding which we are using everyday. But, today we will try to learn about Modifier 32 and Modifier 33 only.

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When to use Modifier 32

Mandated Services

Modifier -32 indicates a service that is required by a third-party entity, Worker’s Compensation, or some other official body. Modifier 32 is no used to report a second opinion request by a patient, a family member or another physician. This modifier is used only when a service is mandated.  For example, an insurer requests an independent evaluation of a patient filing a workers’ compensation claim or an insurer seeks a second opinion on a patient’s condition, prior to authorizing further testing and/or treatment. But do remember the second opinion requested by the patient, or the patient’s family, do not qualify for modifier 32. Neither is modifier 32 used for a consultation with another physician, or when another physician evaluates a patient for medical clearance prior to a procedure. Also, the Medicare generally do not accept modifier 32 and does not pay for the service requested by another provider. So use Modifier 32 only for private or commercial payers.

The third-party payer usually waives the deductible and co-payment for the patient and pays 100% of the service.

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When to use Modifier -33

Preventive Service

Modifier -33 was developed by the American Medical Association (AMA) in response to The Patient Protection and Affordable Care Act (PPACA), which requires health insurers to cover preventive services and immunizations without any cost sharing. Modifier -33 gives providers a way to identify preventive services that do not have a unique CPT code. This modifier also indicates to the payer that it might be appropriate to waive any deductible associated with coinsurance or copayment. This modifier may be used to identify a preventive service that begins as diagnostic, but must be converted to a therapeutic service.

Modifier -33 is applicable in these four categories:

1. US Preventive Services Task Force (USPSTF) grades preventive services:

Grade A: have been judged to have a high certainty that the net benefit is   substantial. 

Grade B: been judged to have a high certainty of moderate to substantial net benefit.

2. Routine immunizations (children, adolescents, and adults), as recommended by the Advisory Committee on Immunization Practices 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.
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.

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All these information will be really helpful for medical coders. It takes a lot of practice in understanding the function of each modifier. During my CPC exam preparation, all of my friend including me, were really struggling to use Modifiers. Till then we had only 59 modifier and no X{EPSU} modifier. But, now we have new X-modifiers. 

Point to remember with Modifier 33

Do not use modifier 33 with Medicare insurance, use this modifier only with private or commercial payers. Medicare do not accept modifier 33.

When a physician provides multiple preventive medical services to the same patient on same day, use modifier 33 to the codes describing preventive service for that day.

The specific preventive services for which cost-sharing does not apply for Medicare patients:

• the initial preventive physical examination;
• the annual wellness visit;
• pneumococcal, influenza, and hepatitis B vaccine and administration;
• screening mammography;
• screening Pap smear and screening pelvic exam;
• prostate cancer screening tests (excluding the digital rectal exam);
• colorectal cancer screening tests;
• bone mass measurement;
• medical nutrition therapy services;
• cardiovascular screening blood tests;
• diabetes screening tests;
• ultrasound screening for abdominal aortic aneurysm;
• additional preventive services (identified for coverage through the national coverage determination; currently, these services are limited to HIV testing); and
• preventive services recommended by the USPSTF that do not have a grade of A or B, including all diagnostic clinical laboratory tests, because the deductible and co-insurance is waived on another basis.

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When to use PT modifier

Modifier PT is more specialized and will be used by fewer practices.  It is a HCPCS modifier, used to indicate that a colorectal screening service converted to a diagnostic or therapeutic service.  Screening colonoscopies are covered by Medicare without a co-pay or deductible.  These screening colonoscopies are billed with HCPCS codes to Medicare (G0105 and G0120).

Although both modifiers (33 and PT) can be used for a colorectal cancer screening service that converts to a diagnostic service, modifier -33 designates all preventive services on the claim.

Take an example of a male patient who comes in for a screening colonoscopy. During the screening, the physician finds something abnormal and performs a polypectomy. The service is now diagnostic. During the same visit, the physician performs a digital prostate exam.

In this example, both procedures started out as screenings, even though the colonoscopy became diagnostic. So coders would append modifier -33 to both codes. However, the digital prostate exam is not a surgical procedure, so ¬coders should not apply modifier -PT; that modifier only applies to surgical services.