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Modifier 33: Not for Medicare

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. A listing of these services is updated and posted annually on the Agency for Healthcare Research and Quality’s website.

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.

Tags: Preventive Care