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New Modifier Impacts Coding of Colonoscopy Claims

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Effective January 1, 2011, Empire recognizes the new modifier PT, which indicates that a colorectal cancer screening test was converted to a diagnostic test or other procedure. This modifier was created to aid compliance with the new health care reform law (the Patient Protection and Affordable Care Act or “PPACA”) which prohibits member cost sharing for defined preventive services for non-grandfathered policies. The appropriate use of modifier PT will reduce claim adjustments related to colorectal screenings and your corresponding refunds to members. The following information shares important guidance about billing this new modifier.  
 
To determine the appropriate use of modifier PT, it is important to ask yourself, “Why is this individual presenting to the office?”  
 
In a situation where an individual presents to the endoscopy suite 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 ensuring 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.  
 
In a circumstance where a patient 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 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.  
 
In the instance that an individual presents to the endoscopy suite 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.  
 
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