Modifier 33

Modifier 33 (2022) Description, Uses, Guidelines & Examples

Modifier 33 appends with services when the physician performs “preventive services.”

Summary

Modifier 33 is appropriate to report with the preventive services and waive off the patient’s deductible, co-pay, and coinsurance with no shared cost. It only applies to commercial insurances such as CIGNA, TUFTS, and BCBS and is inappropriate to append with inherently preventive (preventive counseling and annual exams).

33 is applicable when the physician’s primary intent is to perform the preventive service, which is an evidence-based service under US Preventive Services Task Force A or B or other services that are considered preventive according to the regulation and laws. It is inappropriate to report 33 modifier with services identified explicitly as preventive. 

The following is the list of services that are appropriate to report with modifier 33:

Service or procedure included in the US Preventive Services Task Force (USPSTF) is rated as A or B.

Services or procedures performed for immunizations to adolescents, children, and adults endorse by the US Advisory Committee on Immunization Practices.

Services or procedures performed on children for Preventive care and screenings as suggested by the Bright-Futures-program-of-the-American-Academy-of-Pediatrics. HRSA supports the American College of Medical Genetics for newborn screening.

Services or procedures performed on women (not included in the task force) endorse by the HRSA. For Instance, a High-risk STI patient presents to the office for screening with associated signs and symptoms, but the primary intent is screening. It may report as 99213-33 with DX codes z11.3 and Z72.51 (additional condition). 

CDC recommends HIV screening for every individual between the ages of 13 to 64 at least once, and people who are more at risk of getting HIV should screen frequently. The following are the people who should screen annually:

  • People who are involved in sexual activity for drugs and money.
  • PWID and their sex partners
  • Sex relation with partners who have HIV
  • People with hepatitis, tuberculosis, or sexually transmitted diseases receive treatments.
  • Sexually active MSM requires frequent screening every 3 to 6 months to prevent HIV.
  • People with multiple sex partners, such as Heterosexuals or sex partners, have had more than one partner.
33 modifier

Modifier 33 Description

Modifier 33 appends with services when the physician performs “preventive services.”

What Is Modifier 33?

33 modifier is used with CPT codes to represent preventive or screening studies whose intent is to deliver evidence-based services upon the recommendation of USPSTF.

When To Use Modifier 33

The following are the use 33 when applicable:

33 modifier appropriately reports the preventive service requirements related to PPACA (Patient Protection and Affordable Care Act).

The facility’s primary goal is to deliver an evidence-based service according to US Preventive Services Task Force A or B or services or procedures identified as preventive services mandates (legislative or regulatory). It is appropriate to report modifier 33 with these services.

Modifier 33 Guidelines

Modifier 33 or PT may use to indicate the preventive services. Modifier PT uses Medicare insurance, while 33 modifier is applicable with commercial payors. Modifier PT is relevant when screening converts into the diagnostic. 

Documentation should establish the medical necessity and appropriateness 33 with CPT or HCPCS code. The primary diagnosis code must be preventive or screening.

If the patient presents for screening or preventative reasons, The physician finds nothing in the diagnostic procedure. 33 modifier is stills appropriate to report with the service. 

Modifier 33 helps to lower the claim adjustment relevant to preventive services and refunds the amount to the patient. It only applies to commercial insurances.

33 is inappropriate to report with preventive services that have “screening” or “preventive” in their code descriptor. For Instance, E/M CPT code 99401 does not need to append modifier 33.

It mentions as preventive in the code descriptor. In contrast, CPT 99214 requires 33 modifier when the physician indicates the service as preventive. 

If the physician performs multiple preventive services on the same day, it is appropriate to report modifier 33 with each code. 

33 modifier only applies to the services rendered in conjunction with preventive services, and it is inappropriate to report in combination with other non-preventive services.

33 does not associate with the patient’s benefits and coverage plan and is solely basis on the CPT code and diagnosis code submitted to the insurance or payors. 

Modifier 33 is inappropriate to report with CPT codes which are inherently preventive services such as screening mammography.

Modifier 33 is appropriate to report with services that begin as preventive and converts into therapeutic or diagnostic services. For Instance, the patient presents for a screening colonoscopy (code 45378) and found polyps.

The physician performs polypectomy (code 45383) in addition to 45378. It may bill as 45378-33, 45383.

Modifier PT is used instead of 33 with the service when insurance is Medicare or Medicare Advantage benefit plans. The primary intent is essential for assigning modifier PT to know the patient’s visit is preventive.

For Instance, the patient presents for colorectal cancer screening and converts it into the diagnostic procedure. It may help to reduce the claim adjustments.

If Anesthesia services perform in conjunction with the colonoscopy procedures such as colorectal cancer screening tests, The insurance may waive the deductible, coinsurance, etc. The same rule applies to anesthesia services; the patient does not have to pay coinsurance, which is deducible.

For Instance, Anesthesia procedure codes 00840 bills with 33 or PT on or after January 1, 2015. If these procedure bills without 33 modifier or PT, a Deductible will apply to these services.

The deductible does not apply when the PT or 33 attaches to the service ranges from CPT codes 10000-69999 or HCPCS codes G6018-G6028 on the claim for procedures performed on the same day. 

Modifier 33 is inappropriate to use with Routine immunizations advised for persons living in the United States to inhibit communicable diseases are inherently preventive. 

33 modifier is inappropriate to use with Preventive medicine services such as 99406-99412, 99391-99397, 99381-99387, and 99401- 99404.

33 is inappropriate to use with E/M visit codes (99201-99499) which are inherently preventive.

Modifier 33 Examples

The following are the example bills with modifier 33:

Example 1

A 30-year-old female with no PMH presents to the office for COVID-19 screening. The patient has no sign-and symptoms related to COVID-19. He just showed up for a preventive visit. He is following a healthy routine and diet.

The physical exam was unremarkable. The appearance seems normal and healthy patient. The patient has no issues related to reparatory systems, cardiovascular, headache, numbness, vomiting, and nausea. The physician reviews all the systems and negative.

The physician ordered COVID-19 screening tests, and they became negative. It is appropriate to report the office visit 99201-99215 with 33 modifier for a preventive visit.

If the visit is related to annual wellness or preventive medicines, it is inappropriate to report 33 with the service.

Example 2

A 30-year-old female with no PMH presents to the office for HIV screening. The patient has no sign-and symptoms related to HIV. He has no other signs and symptoms and maintains healthy life and activities. 

The physical exam was unremarkable, and the appearance seemed normal and healthy patient. The patient has no issues related to reparatory systems, cardiovascular, headache, numbness, vomiting, and nausea. The physician reviews all the systems and negative.

The physician ordered HIV screening tests, and they became negative. It is appropriate to report the office visit 99201-99215 for HIV screening with modifier 33 for a preventive visit.

The appropriate DX with the preventive visit is Z20.6, Z11.3, Z20.2, Z11.47, Z11.59, Z20.5, and Z71.7. These DX codes should list as the primary Dx code for reimbursement. If diagnosis relates to the sign and symptoms as primary dx, It may deny by the insurance as a medical necessity. 

Example 3

A 30-year-old female with no PMH presents to the office for Colorectal screening. The patient has no family or personal history of colon polyps. He follows a healthy diet routine and has no other significant concerns.

The physical exam was negative and unremarkable. The appearance seems normal and healthy patient.

The patient has no cardiovascular, reparatory systems issues, headache, numbness, vomiting, or nausea. The physician reviews all the systems and negative. 

Colonoscopy may perform as diagnostic, therapeutic, or preventive. The physician ordered colon screening with the administration of anesthesia. If insurance is commercial, adding 33 modifier on the claim is appropriate.

Suppose the patient’s age is greater than 50 with no signs and symptoms and presents for colorectal cancer screening. This visit considers a preventive visit and reports 33 with diagnosis code V76.51.

If the same patient presents with symptoms, I will be considered a diagnostic service. It is inappropriate to append 33 modifier with the diagnostic service. If the patient presents with a history of colon polyps and is asymptomatic, 33 can report on the claim.

99497 Modifier 33

CPT 99497 appends with the service when the physician performs face-to-face Advance care planning for the first 30 minutes with the patient, surrogate, or family members.

It is appropriate to report modifier 33 with CPT code 99497 when an annual wellness visit performs in conjunction with an Advance care planning visit (99497).

Cost Sharing Of Modifier 33

The regulations specify that plans cannot impose cost-sharing requirements, such as co-pays, coinsurance, or deductibles with respect to specified preventive services in which preventive services are billed separately.

When these 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.

However, cost-sharing is permitted for an office visit when the office visit and covered preventive services are billed separately, and the primary purpose of the office visit is not delivery of the covered preventive services.

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