More on Modifier 33

June 15, 2011

I keep hearing about the new modifier 33 but it's not in the CPT manual. Am I supposed to be using it?

Question: I keep hearing about the new modifier 33 but it's not in the CPT manual. Am I supposed to be using it? (From the February 2011 journal.)

Answer: Yes you are, but it may be difficult to determine when to use it for given payers and given services. CPT 2011 went to print long before the AMA put the modifier information on their website. In fairness, this is a response to healthcare reform and by necessity came late in the year.CPT has created a new modifier 33 - which allows providers to report to payers that a given preventive service is covered under new healthcare laws and that patient cost sharing does not apply.

The Patient Protection and Affordable Care Act made it mandatory for all healthcare insurance plans to start to cover some preventive services and immunizations as part of all benefit plans and not subject to deductibles and copays for some specified preventive services. This is called first-dollar-coverage and means that "cost sharing" - or copays and deductibles - aren't applicable to these services.

This modifier may also be used when a service began as a preventive service and was converted to a therapeutic service. The example the AMA gives is a screening colonoscopy converted to a polypectomy.

You will need to find out which plans are converting at their next renewal period to meet the new law. Then you'll need to identify which services they now cover as preventive to which modifier 33 applies. This will require some work on your end payer by payer.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the April 2011 issue of Physicians Practice.