Modifier 33 can be appended to CPT codes that include services when the physician performs preventive services.
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).
The official description of modifier 33 is: “Preventive Services”
The 33 modifier applies 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 considered preventive according to the regulation and laws. It is inappropriate to report 33 modifiers 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 relations 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.
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 or PT may use to indicate the preventive services. Modifier PT uses Medicare insurance, while the 33 modifier applies to 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 insurance.
33 is inappropriate to report preventive services with “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 the 33 modifier when the physician indicates the service as preventive.
If the physician performs multiple preventive services on the same day, reporting modifier 33 with each code is appropriate.
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 and diagnosis codes submitted to the insurance or payors.
Modifier 33 is inappropriate to report with CPT codes, 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 Routine immunizations advised for persons living in the United States to inhibit communicable diseases are inherently preventive.
33 modifier is inappropriate for 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.
The case below describes a procedure that require modifier 33 to be appended to the claim.
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, or 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, reporting the 33 modifier with the service is inappropriate.