Modifiers 33 and PT are used to inform payers that a service provided was either initiated as or fully performed as a screening. These modifiers are essential when the HCPCS code used does not explicitly describe the service as a screening.
Modifier -33 and Medicare
Modifier -33 is not recognized by Medicare, which instead requires the use of modifier -PT for most services. However, modifier -33 may be used in specific cases, such as:
- Anesthesia services provided in conjunction with screening colonoscopies.
- Advance care planning CPT codes (99497, 99498), which include discussions about advance directives.
In these instances, modifier -33 should be used for professional fee services (not outpatient hospital services). For all other situations, Medicare requires modifier -PT.
When to Use Modifiers -33 and -PT
Both modifiers are used to indicate that the primary purpose of the service was preventive or screening-based. This can include services recommended by the U.S. Preventive Services Task Force (USPSTF) with an A or B rating, as well as other preventive services mandated by legislative or regulatory guidelines.
These modifiers should be appended to the relevant procedure code to notify the payer that the service was intended as a screening, which may remove patient cost-sharing responsibilities under the Affordable Care Act (ACA).
When Not to Use Modifiers -33 and -PT
If a service is inherently preventive (e.g., a screening colonoscopy with a specific HCPCS code for screening), the modifier is not necessary, as the payer will already recognize it as a screening. These modifiers are generally used for services that can be either preventive or diagnostic, such as the lipid panel (CPT code 80061).
Example of Modifier -33 Usage:
A 45-year-old male receives a cholesterol screening test (CPT code 80061) during a routine clinic visit. Although he does not have high cholesterol, he has a family history of it. In this case, modifier -33 is appended to the CPT code to indicate that the test was performed as a preventive service.
Modifier -33 or -PT for Services Transitioning from Screening to Diagnostic:
In some cases, a service may begin as a screening but then become a diagnostic procedure based on the results. When this happens, either modifier -33 or -PT should be appended to the diagnostic code to inform the payer that the service started as a screening.
For example, in a screening colonoscopy where polyps are discovered and biopsied, the modifier is applied to the diagnostic code to indicate that the procedure began as a screening.
Medicare-Specific Guidelines:
Medicare requires modifier -PT when billing for diagnostic lower gastrointestinal endoscopies that began as a screening. This is relevant when a screening colonoscopy transitions to a diagnostic procedure, such as when polyps are found during the exam.
It’s important to note that a colonoscopy performed for symptoms such as changes in bowel habits, rectal bleeding, or anemia would be considered diagnostic from the start, and modifier -PT should not be used.
Coding Scenarios
- Scenario 1: A Medicare patient is eligible for a screening colonoscopy. The previous colonoscopy was 13 years ago and normal. The patient has no history of polyps or colorectal cancer. The appropriate code for this screening is G0121, which is used for colorectal cancer screening for patients not at high risk.
- Scenario 2: During a screening colonoscopy, a polyp is found and biopsied. The procedure transitions to a diagnostic colonoscopy with biopsy. The correct code for this scenario is 45380-PT, indicating that the colonoscopy began as a screening but became diagnostic when polyps were discovered.
Summary
Modifiers -33 and -PT help distinguish services that began as screening procedures and transitioned into diagnostic services. Proper use of these modifiers ensures accurate billing and compliance with payer guidelines, including those set by Medicare.