Surgery Center Coding Guidance: Use of Modifiers -PT and -33
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Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
Colon cancer screening is one of a number of procedures that fall under preventive care and services for which the patient may not have to pay a copayment, coinsurance or deductible. However, there are times when a patient will present for a colon cancer screening and a polyp or lesion is removed, so the screening now becomes a diagnostic procedure. By appending modifier -PT (for Medicare patients) or modifier -33 (for commercial plans), it alerts carriers to the fact that the original procedure was a screening and any fees should be waived.
Modifiers -PT and -33 should not be used for all accounts because patients are only eligible for provisions of the Patient Protection and Affordable Care Act when the following conditions are met.
Patient Protection and Affordable Care Act
1. A patient has obtained a new health insurance plan or insurance policy beginning on or after September 23, 2010, then specific preventive services must be covered without the patient having to pay any out of pocket expense. This applies only when these services are delivered by a network provider.
2. The provisions of the PPAC Act apply when, between the dates of March 23, 2010 and September 22, 2010:
- A patient has obtained a new individual or family health plan, or
- The employer did not previously offer coverage and obtains a new health plan
The patient then becomes eligible:
- Individual plan (on the anniversary date, calendar year date or when the plan begins to calculate the annual deductible)
- Family/group plan (new plan year or date when policy is renewed)
- The date that employer obtained new policy
What's important about this information is that coders and billers understand when modifiers -PT and -33 are used. Facilities should be performing insurance verification and noting the effective date of a patient's policy. If the patient is scheduled for a screening colonoscopy and a polyp is removed and the effective date of the patient's policy is on or after Sept. 23, 2010, then modifiers -PT (Medicare) or -33 (commercial) would be appended. Many plans in place before Sept. 23, 2010, have been grandfathered, meaning those patients do not receive benefits under the PPAC Act so -PT and -33 modifiers are not used.
By verifying the patient's insurance information and applying the provisions of the PPAC Act, facilities will know when it's appropriate to collect the co-payment or deductible that's due on the date of service. If there's any question as to whether or not the patient has a financial responsibility, get clarification from the carrier.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
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