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Anesthesia Furnished in Conjunction with Colonoscopy (Modifier 33 Versus Modifier PT) Policy Update
In the CY 2018 PFS Final Rule, the CMS modified reporting and payment for anesthesia services furnished in conjunction with and in support of colorectal cancer screening services.
Anesthesia services furnished in conjunction with and in support of a screening colonoscopy are reported with CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy). CPT Code 00812 will be added as part of 1/1/2018 HCPCS update. Effective for claims with dates of service on or after 1/1/2018, Medicare will pay claim lines with new CPT code 00812 and waive the deductible and coinsurance.
When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified) and with the PT modifier. CPT code 00811 will be added as part of the 1/1/2018 HCPCS update. Effective for claims with dates of service on or after 1/1/2018, Medicare will pay claim lines with new CPT code 00811 and waive only the deductible when submitted with the PT modifier.
The information below was addressed in MM8874 regarding the addition of a modifier to anesthesia procedure 00810 so that procedure would be exempt from coinsurance and deductible.
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 1/1/2011.
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 1/1/2015, 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.
This issue was also further discussed in the CY 2015 PFS Final Rule in which CMS further advised the information below.
Section 1833(b)(1) of the Act, as amended by section 4104(c) of the Affordable Care Act, waives the Part B deductible for colorectal cancer screening tests regardless of the code billed for the establishment of a diagnosis as a result of the test, or the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as a screening test. The statutory waiver of deductible will apply to the anesthesia services furnished in conjunction with a colorectal cancer screening test even when a polyp or other tissue is removed during a colonoscopy. As in the case of the physician furnishing the colonoscopy service, the anesthesia professional reporting the anesthesia in conjunction with the colonoscopy where a polyp is removed would also report the PT modifier.
Effective 1/1/2015, beneficiary coinsurance and deductible do not apply to the following anesthesia claim lines billed when furnished in conjunction with screening colonoscopy services and billed with the appropriate modifier (33): 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum). Anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a colorectal cancer screening test should include the 33 modifier on the claim line with the anesthesia service. As noted above in situations that begin as a colorectal cancer screening test, but for which another service such as colonoscopy with polyp removal is actually furnished, the anesthesia professional should report a PT modifier on the claim line rather than the 33 modifier.
Since the January 2015 MCS System Release only included modifier 33 as being valid for submission with CPT 00810 for waiving the deductible and coinsurance that is what the MCS system allowed for on submission. Based on the full range of guidance provided by CMS through the final rule, National Government Services has determined that a policy revision is warranted to allow modifier PT with CPT 00810 for those situations when a colonoscopy started as screening and additional work was done making it diagnostic. We have made this change in our processing system effective, 2/25/2015.
If you have claims that were submitted in this manner and have been denied then you may resubmit them for consideration with this change in policy.