CODING & DOCUMENTATION
Fam Pract Manag. 2016 Jul-Aug;23(4):38.
Author disclosure: no relevant financial affiliations disclosed.
When should our office use the new modifier 33?
Modifier 33 was added in response to the Patient Protection and Affordable Care Act provision that requires insurers to cover certain preventive services and immunizations without cost sharing to the patient. When billing for services that could be either preventive or diagnostic (e.g., 45378, Colonoscopy), use modifier 33 to indicate that the code represents a covered preventive service. This ensures that the patient will not be subject to a copayment or deductible. However, if a service is already identified as preventive within the definition, do not use modifier 33 (e.g., 77057, Screening mammography, bilateral).
ICD-10 coding for preventive visits
How should I report ICD-10 codes for preventive visits with and without abnormal findings?
A Report a code for the preventive service with an abnormal finding only when the finding is a new problem identified at this encounter or when there is increased severity or inadequate control of an existing problem. These instructions apply to codes for routine examinations for adults (Z00.00-Z00.01) and children (Z00.121-Z00.129) and for routine gynecological examinations (Z01.411-Z01.419). The following examples show how to report an adult preventive service with and without abnormal findings.
You note a mole that is suspicious for malignancy. The suspicious mole is a new abnormal finding. Report Z00.01, “Encounter for general adult medical examination with abnormal findings,” and the appropriate code for the suspicious mole.
You note that the patient is due for reevaluation of congestive heart failure (CHF), finding the condition to be well-controlled with current management. This is not an abnormal finding. Report Z00.00, “Encounter for general adult medical examination without abnormal findings,” and the appropriate code for the CHF.
Editor's note: Some payers may not agree with the advice given. Refer to current coding manuals and payer policies.
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Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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