New Modifier 33 in OCE Update

March 15th, 2011

The new outpatient CPT® modifier 33 is one of the many changes announced in the latest update to the Outpatient Code Editor Version 12.1, effective April 4, 2011, by the Centers for Medicare & Medicaid Services (CMS), but it’s the most noteworthy. Modifier 33 Preventive services is effective retroactively Jan. 1, 2011, according to CMS Transmittal 2172. The modifier is not in the CPT® 2011 Professional Edition code book. It can be used with both CPT® and HCPCS Level II prevention codes, but should not be appended to codes for services that are inherently preventive.

The modifier was developed by the American Medical Association (AMA) to assist in fulfilling an aspect of the Patient Protection and Affordable Care Act (PPACA). The PPACA requires all health care insurance plans to begin covering preventive services and immunization without any cost sharing. These benefits go into effect when plans renew or change. AMA says modifier 33 was created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws with no patient cost-sharing. AMA’s example is a screening colonoscopy (45378) resulting in a polypectomy (45383). However, if the service is inherently preventive, such as a screening mammography, modifier should not be appended.

The official AMA description is as follows:

Modifier 33, Preventive Service: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, Preventive service, to the service. For separately reported services specifically identified as preventive, the modifier should not be used.

Other changes to the Outpatient Code Editor used for Outpatient Prospective Payment System (OPPS) and ambulatory surgery center providers include:

  • Modifying the software to maintain 28 prior quarters of programs in each release
  • Implementing version 17.0 of the Correct Coding Initiative (CCI)
  • Removing code 88177 from the female procedures list

More can be found in CMS Transmittal 2172.


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8 Responses to New Modifier 33 in OCE Update

  1. Louise Hayes Says:

    Is there an actual list of codes- not just a description from the (USPSTF A and B list) task force site….that can be used as a reference as codes that are inherently preventative should not have mod 33 appended? thanks

  2. Canda Lindke Says:

    Medicare has a list of the codes and if the cost sharing is waived or not for them.

    http://www.cms.gov/Transmittals/downloads/R864OTN.pdf

  3. Corinne A Littleton Says:

    The AMA has a couple of free downloadable documents it created for the new preventive services that are covered PPACA’s mandate of first dollar coverage of preventive services. Of course it’s aimed at Medicare patients but it’s a nice start.

    http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/medicare-preventive-services.page?

  4. DEBBIE Says:

    HOWS DOES THIS CODE EFFECT ANESTHESIA

  5. Marcia Says:

    Has anyone responded as to how this will effect anesthesia? Thanks

  6. Brad Says:

    We checked with other sources like CMS. It probably doesn’t affect anesthesia coding. Whereas a preventive procedure such as a colonoscopy might have anesthesia, there are precious few preventive assessments or vaccinations where the 33 might be appended where anesthesia would be used or wouldn’t be an instrinsic part of the procedure. If the preventive procedure was a colonoscopy, either the physician would provide anesthesia and/or the procedure would have PT modifier attached to it.

  7. Becky Says:

    What is the difference between the 33 modifier and the PT modifier?

  8. brad Says:

    Coding Edge has had several good articles about modifiers 33 and PT, the most recent of which was in May 2012.

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