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Jamie Posted 1 Year(s) ago
Patient present to office for Annual Preventive Exam. The patient has stable Hyperlipidemia and stable diabetes. As part of the preventive exam a review of pre-existing conditions, ie. HDL and DM, is done. The provider orders labs to check status of stable Hyperlipidemia and Diabetes. The primary diagnosis for the labs would be E78.5 (HDL) and E11.9 (diabetes), since the screening codes would not apply. Since the primary purpose of the visit is preventive, would modifier 33, appended to the labs, be appropriate for billing purposes? Can modifier 33 be appended to any CPT code?
SuperCoder Posted 1 Year(s) ago


Our team is working on it. We will get back to you soon.

SuperCoder Posted 1 Year(s) ago

Yes, modifier 33 would be appended with labs.

Modifier 33 is appropriate with a CPT or HCPCS code that is a diagnostic/therapeutic service that is being performed as a preventive service.

Modifier 33 is applied to indicate that a preventive or screening service has taken place. The modifier may waive a patient's co-pay, deductible, and co-insurance so that there is no cost sharing. This modifier is only used on claims for commercial payers. The modifier 33 does not have to be appended to those services that are inherently preventive.


Jamie Posted 1 Year(s) ago
So even though the tests are being performed for diagnostic purposes we still add 33 to indicate a preventative or screening service when its a diagnostic test?
SuperCoder Posted 1 Year(s) ago

Yes, Modifier 33 would be used with codes for services that could be either preventive or diagnostic, to identify that the service rendered or ordered was for preventive health purposes.

Jamie Posted 1 Year(s) ago
If Pt presents to office for sinusitis. During visit, provider orders lipid panel, 80061, for screening purposes with DX of Z13.220. Does Modifier 33 need to be applied in this scenario?
SuperCoder Posted 1 Year(s) ago

The AMA created modifier 33 Preventive Service to alert an insurer that the provider is billing a service covered under the Patient Protection and Affordable Care Act (PPACA), for which patient cost sharing does not apply. You may apply modifier 33 for falling into one of four categories:

1. Services rated “A” or “B” by the US Preventive Services Task Force (USPSTF). Services with an “A” rating have been judged to have a high certainty that the net benefit is substantial. Services with a “B” rating have been judged to have a high certainty of moderate to substantial net benefit.

2. Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics), as supported by the Health Resources and Services Administration.

3. Preventive care and screenings provided for women (not included in the Task Force recommendations) in the comprehensive guidelines supported by the Health Resources and Services Administration.

Examples of the above include HIV screening in adults and adolescents at increased risk for HIV infection, bacteriuria screening for pregnant women, blood pressure screening in adults, and colorectal cancer screening in adults beginning at age 50.

4. Immunizations for routine use in children, adolescents, and adults, as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Examples include zostavax immunization in adults; inactivated polivirus for children; and Hepatitis A and B, human papillomarivirus, measles, mumps, and rebulla, and influenza for both adults and children.

You may also apply modifier 33 when a preventive service must be converted to a therapeutic service (for instance, when screening colonoscopy [45378] results in a polypectomy [e.g., 45383]). 

There are two important circumstances in which you should not apply modifier 33:

1. Do not append modifier 33 for separately reported services specifically identified as preventive,” such as 77057 Screening mammography, bilateral 92-view film study of each breast.

2. Do not append modifier 33 for Medicare or Medicaid claims. Claims submitted to Medicare with modifier 33 will be returned with Medicare Outpatient Adjudication (MOA) code MA130, which indicates that the claim contains incomplete and/or invalid information and is therefore “unprocessable.” As such, you should only append modifier 33 for non-Medicare payers, as per AMA instructions.

Medicare requires the use of dedicated G codes that specifically describe covered services as preventive (for instance, G0202 Screening mammography, producing direct digital image, bilateral, all views).

Insurers are permitted to require cost sharing for those services that are not covered under PPACA. Insurers also are permitted to impose cost sharing—or choose not to provide coverage—for recommended preventive services that are provided out-of-network.

Posted by Jamie, 1 Year(s). There are 7 posts. The latest reply is from SuperCoder.

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