Monday, October 19, 2015

Colorectal Cancer Screening modifiers 33 and PT

Colorectal Cancer Screening

Based on the Centers for Medicare and Medicaid Services (CMS), two modifiers may be used to identify anesthesia services rendered in conjunction with a screening service.

• Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with United States Preventive Task Force A or B rating in effect and other preventive services Appending the 33 modifier will waive patient’s deductible and co-insurance.

Providers can append Modifier 33 to indicate that the screening colonoscopy (45378) was converted to a polypectomy (45383). In this scenario Modifier 33 is appended to 45383 will ensure that the claim is paid correctly. Modifier 33 will impact how the claim is paid only for colonoscopy procedures. Modifier 33 should not be applied to nonpreventive colonoscopies (done to evaluate signs, symptoms, follow-up or existing conditions).


• Modifier PT – Colorectal cancer screening test; converted to diagnostic test or other procedure. Appending the PT modifier will waive the patient’s deductible. Co-insurance will still apply.

Coverage Guidance

Cancer screening is a means of detecting disease early, in asymptomatic individuals, with the goal of decreasing morbidity and mortality. Generally, screening examinations, tests, or procedures are not diagnostic of cancer but instead indicate that a cancer may be present. The diagnosis is then made following a workup that generally includes a biopsy and pathologic confirmation. Colorectal cancer screening involves the use of fecal occult blood testing, rigid and flexible sigmoidoscopy, radiographic barium contrast studies, and colonoscopy.

Effective for services furnished on or after January 1, 1998, Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. The following are the coverage criteria for these screening services:

• Annual fecal occult blood tests (FOBTs);
• Flexible sigmoidoscopy over 4 years;
• Screening colonoscopy for persons at average risk for colorectal cancer every 10 years,
• Screening colonoscopy for persons at high risk* for colorectal cancer every 2 years;
• Barium enema every 4 years as an alternative to flexible sigmoidoscopy, or
• Barium enema every 2 years as an alternative to colonoscopy for persons at high risk* for colorectal cancer;


* Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:


• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of familial adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer; or
• A personal history of inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis

It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.

Fecal Occult Blood Tests (FOBT)

• The FOBTs are generally divided into two types: immunoassay and guaiac types.

1. Immunoassay (or immunochemical) fecal occult blood tests (iFOBT) use “antibodies directed against human globin epitopes. While most iFOBTs use spatulas to collect stool samples, some use a brush to collect toilet water surrounding the stool. Most iFOBTs require laboratory processing.

2. Guaiac fecal occult blood tests (gFOBT) use a peroxidase reaction to indicate presence of the heme portion of hemoglobin. Guaiac turns blue after oxidation by oxidants or peroxidases in the presence of an oxygen donor such as hydrogen peroxide. Most FOBTs use sticks to collect stool samples and may be developed in a physician’s office or a laboratory

• Medicare covers one screening FOBT per annum for the early detection of colorectal cancer. This means that Medicare will cover one guaiac-based (gFOBT) or one immunoassay-based (iFOBT) at a frequency of every 12 months; i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed, for beneficiaries aged 50 years and older. The beneficiary completes the existing gFOBT by taking samples from two different sites of three consecutive stools; the beneficiary completes the iFOBT by taking the appropriate number of stool samples according to the specific manufacturer’s instructions. This screening requires a written order from the beneficiary’s attending physician , or for claims with dates of service on or after January 27, 2014, by a beneficiary’s attending physician assistant, nurse practitioner, or clinical nurse specialist

Colonoscopy and Sigmoidoscopy

• These endoscopy procedures should be performed by a doctor of medicine or osteopathy.

• If during the course of a screening endoscopy procedure a lesion is detected which results in biopsy or removal of the growth, the appropriate diagnostic CPT procedure should be billed rather than the screening procedure.

• When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met.

• Anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy shall bill CPT code 00810: Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum and append modifier 33 to indicate that services that qualify for the waiver of coinsurance and deductible:

Barium Enema Alternative to Sigmoidoscopy or Colonoscopy

The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. This screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination.

Billing Guidelines

Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance. Modifier 33** The appropriate use of modifier 33 will help reduce claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 applies to commercial lines of business only.

** CPT modifier 33 is applicable to preventive services that do not have a unique code for such services (e.g., E&M codes such as, 99401 would not require modifier 33 as this code already indicates a preventive medicine service. However, code 99213
would require modifier 33 when the provider indicates that the service was preventive).

** If multiple preventive medicine services are provided on the same day, then the modifier is appended to the codes for each preventive service rendered on that day.

** Modifier 33 should be used when only preventive services were rendered on that date, not when combined with other non-preventive services.

** CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.

** CPT codes identified as inherently preventive, (e.g., screening mammography) should not be appended with modifier 33.

** This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).

Additional information about modifier 33 is available via the American Medical Association website, http://www.ama-assn.org/ama1/pub/upload/mm/362/new-cpt-modifier-for-preventiveservices. pdf.

Modifier PT ** Modifier PT applies to Medicare products only (Medicare Advantage and Medicare Supplemental). To determine the appropriate use of modifier PT, it’s important to know why the member is presenting for treatment.

Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or other procedure (impacts colonoscopy and sigmoidoscopy codes). The appropriate use of modifier PT will help reduce claim adjustments related to colorectal screenings and your corresponding refunds to members.

Please see the following scenarios for guidance:

** Screening exam only: In a situation where a member presents for treatment solely for the purpose of a screening exam, without any signs or symptoms of a disease, then such a procedure should be considered a screening. The appropriate use of diagnosis codes and screening procedure codes is valuable in promoting appropriate adjudication of the claim. The use of the modifier PT in conjunction with a CPT procedure or HCPCS code that is defined as a screening based on that code’s description is not necessary.

** Treatment due to signs or symptoms to rule out or confirm a suspected diagnosis: In the instance that a member presents for treatment due to signs or symptoms to rule out or confirm a suspected diagnosis, such an encounter should be considered a diagnostic exam, not a screening exam. In such a situation, the modifier PT should not be used and the sign or symptom
should be used to explain the reason for the test.

** Screening colorectal exam converted to a diagnostic service: In a circumstance where a member presents for a screening exam (without signs or symptoms), and an issue is encountered during that preventive exam, then such a circumstance would warrant the use of the PT modifier. The procedure and diagnosis codes that would typically be used in such an instance may not clearly demonstrate that the service began as a screening procedure, but had to be converted to a diagnostic procedure due to a pathologic finding (e.g., polyp, tumor, bleeding) encountered during that preventive exam. The use of the PT modifier in the instance of a screening colorectal exam being converted to a diagnostic service would clarify that despite the end result the service began as a screening service.


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