New CPT Modifier 33 for Preventive Services under PPACA
Effective January 1, 2011, Empire recognizes the new CPT modifier 33, Preventive Service. 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 33 will reduce claim adjustments related to preventive services and your corresponding refunds to members. The following information shares important guidance about billing this new modifier.
CPT modifier 33 is applicable to codes falling under recommendations by the PPACA of 2010 for the identification of preventive services without cost-sharing. 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. 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.
Modifier 33 should only be appended to codes represented in one or more of the following four categories:
1. Services rated "A" or "B" by the US Preventive Services Task Force (USPSTF)
2. 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
3. Preventive care and screenings for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics)
4. Preventive care and screenings provided for women supported by the Health Resources and Services Administration.
CPT codes identified as inherently preventive, (e.g., a screening mammography) and services not indicated in the categories noted above should not be appended with the modifier 33.
Additional details about the appropriate billing of modifier 33 are available in this recent AMA publication.