Description for PT modifier
Colorectal cancer screening test; converted to diagnostic test or other procedure.
Guidelines
- This modifier is effective for dates of service on or after January 1, 2011
- Submit this modifier with the appropriate CPT code for colonoscopy, flexible Sigmoidoscopy, or barium enema when the service is initiated as a colorectal cancer screening service but becomes a diagnostic service
- This modifier is valid for CPT codes 10000-69999
- The Part B deductible and coinsurance do not apply to these services
Medicare CRC Screening: Diagnostic Modifier-PT
Modifier-PT (CRC screening test, converted to diagnostic test or other procedure) to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code, or as a result of the barium enema when the screening test becomes a diagnostic service. The claims processing system would respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test. Coinsurance for Medicare beneficiaries would continue to apply to the diagnostic test and to other services furnished in connection with, as a result of, and in the same clinical encounter as the screening test.
New Modifier Impacts Coding of Colonoscopy Claims
Effective January 1, 2011, for professional claims, Anthem Blue Cross and Blue Shield (Anthem) 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 nongrandfathered 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 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 on professional claims.
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.
Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or therapeutic procedure.
Adding Modifier PT to all service lines related to the procedure when a screening colonoscopy or flexible sigmoidoscopy becomes a diagnostic service or therapeutic procedure on the same date of service will waive the deductible for the related
surgical services. No copay will apply.
Correct Use of Modifier PT
Procedure Code Range Copay / Deductible
Screening Colonoscopy or Flexible Sigmoidoscopy
CPT Codes: 45355 or 45330
ICD9 Diagnosis Codes: V10.05, V16.0, V76.41, V76.51, V76.52, V76.89, V76.9
No copay applies
Screening Colonoscopy or Flexible Sigmoidoscopy converted to diagnostic test or therapeutic procedure.
CPT Codes: 45378-45392, 45331-45345, G0104-G0106, G0120-G0121, 74270
No copay applies when Modifier PT is added to the diagnostic test or therapeutic procedure code.
Deductible is waived for surgical services related to the colonoscopy / sigmoidoscopy on the same day as the screening test.
Add Modifier PT to all service lines related to the procedure.
Colonoscopy Billing Reminder- Preventive vs. Diagnostic
The Affordable Care Act (ACA or health care reform law) requires nongrandfathered health plans to cover outlined preventive care and screenings without member cost sharing, when the services are rendered by an in-network provider and/or facility. Colorectal cancer screenings are included as a covered preventive care service under these guidelines.
Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate ICD-9 diagnosis coding guidelines when reporting colonoscopies. When inappropriate ICD-9 diagnosis codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.
To reduce claim adjustments and your corresponding refunds to members, we recommend the following approach when coding a colonoscopy claim.
• In a situation where an individual 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.
• In a circumstance where an individual 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.
• In the instance that an individual 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.
Anesthesia Furnished in Conjunction with Colonoscopy
Section 4104 of the Affordable Care Act defined the term “preventive services” to include “colorectal cancer screening tests” and as a result it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of the Act for screening colonoscopies. In addition, the Affordable Care Act amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or after January 1, 2011.
In the CY 2015 PFS Proposed Rule, CMS proposed to revise the definition of “colorectal cancer screening tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal. The definition of “colorectal cancer screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies in the Medicare regulations at Section 410.37(a)(1)(iii). As a result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with screening colonoscopies.
As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia
professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code 00810 performed in conjunction with G0105 and G0121) shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible:
Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But,MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.
Modifier-PT (CRC screening test, converted to diagnostic test or other procedure) to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code, or as a result of the barium enema when the screening test becomes a diagnostic service. The claims processing system would respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test. Coinsurance for Medicare beneficiaries would continue to apply to the diagnostic test and to other services furnished in connection with, as a result of, and in the same clinical encounter as the screening test.
New Modifier Impacts Coding of Colonoscopy Claims
Effective January 1, 2011, for professional claims, Anthem Blue Cross and Blue Shield (Anthem) 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 nongrandfathered 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 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 on professional claims.
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.
Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or therapeutic procedure.
Adding Modifier PT to all service lines related to the procedure when a screening colonoscopy or flexible sigmoidoscopy becomes a diagnostic service or therapeutic procedure on the same date of service will waive the deductible for the related
surgical services. No copay will apply.
Correct Use of Modifier PT
Procedure Code Range Copay / Deductible
Screening Colonoscopy or Flexible Sigmoidoscopy
CPT Codes: 45355 or 45330
ICD9 Diagnosis Codes: V10.05, V16.0, V76.41, V76.51, V76.52, V76.89, V76.9
No copay applies
Screening Colonoscopy or Flexible Sigmoidoscopy converted to diagnostic test or therapeutic procedure.
CPT Codes: 45378-45392, 45331-45345, G0104-G0106, G0120-G0121, 74270
No copay applies when Modifier PT is added to the diagnostic test or therapeutic procedure code.
Deductible is waived for surgical services related to the colonoscopy / sigmoidoscopy on the same day as the screening test.
Add Modifier PT to all service lines related to the procedure.
Colonoscopy Billing Reminder- Preventive vs. Diagnostic
The Affordable Care Act (ACA or health care reform law) requires nongrandfathered health plans to cover outlined preventive care and screenings without member cost sharing, when the services are rendered by an in-network provider and/or facility. Colorectal cancer screenings are included as a covered preventive care service under these guidelines.
Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate ICD-9 diagnosis coding guidelines when reporting colonoscopies. When inappropriate ICD-9 diagnosis codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.
To reduce claim adjustments and your corresponding refunds to members, we recommend the following approach when coding a colonoscopy claim.
• In a situation where an individual 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.
• In a circumstance where an individual 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.
• In the instance that an individual 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.
Anesthesia Furnished in Conjunction with Colonoscopy
Section 4104 of the Affordable Care Act defined the term “preventive services” to include “colorectal cancer screening tests” and as a result it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of the Act for screening colonoscopies. In addition, the Affordable Care Act amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or after January 1, 2011.
In the CY 2015 PFS Proposed Rule, CMS proposed to revise the definition of “colorectal cancer screening tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal. The definition of “colorectal cancer screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies in the Medicare regulations at Section 410.37(a)(1)(iii). As a result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with screening colonoscopies.
As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia
professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code 00810 performed in conjunction with G0105 and G0121) shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible:
Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But,MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.
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