Health Information Management

Q/A: Correct use of modifier -PT

APCs Insider, January 21, 2011

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Q: We’ve seen very little information about the new modifier –PT, which denotes a colorectal cancer screening test that is converted to diagnostic test or other procedure. Can you provide information about proper use of this modifier?

A: In response to a provision in the Affordable Care Act (ACA), CMS created this new HCPCS modifier for Medicare claims beginning January 1. Append this modifier to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code. You also should append it when a the screening test becomes a diagnostic service based on the results of a barium enema.

The ACA waives the Part B deductible for colorectal cancer screening tests that become diagnostic. Specifically, section 4104(c)(2) waives the deductible with respect to a colorectal cancer screening test regardless of the code billed to establish diagnosis as a result of the test, or for removal of tissue or other matter or other procedure furnished in connection with, as a result of, and in the same clinical encounter as a screening test.

Medicare policy states that the deductible is waived for all surgical procedures (CPT code range of 10000–69999) furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema when the procedure was initiated as a colorectal cancer screening service.

Append modifier -PT to the diagnostic procedure code reported to indicate that this procedure began as a screening colonoscopy or screening sigmoidoscopy. The claims processing system should respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test. Co-insurance 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.

For example, a Medicare patient presents for a screening colonoscopy due to a cecum polyp that was removed three years ago. The patient currently has no signs or symptoms. This patient has a high risk determination (history of colon polyps, denoted by HCPCScodeV12.72) so the procedure would be scheduled as a screening colonoscopy on an individual at high risk (HCPCS G0105). During the screening exam, the physician discovers a polyp in the sigmoid colon and removes it with a snare technique. Based on the definition of and requirements for modifier -PT, the correct code assignment for this scenario is 45385-PT. The claims processing system should read this as the initial procedure was expected to be a screening colonoscopy but a polyp was identified and removed in the same encounter.

Editor’s note: Denise Williams, RN, CPC-H, Director of Revenue Integrity Services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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