Codapedia is now a division of Find-A-Code

AMA vs Medicare rules and the use of the PT modifier

May 22nd, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Medicare   Preventive Medicine Service   CPT® Coding  
0 Votes - Sign in to vote or comment.

Be sure to review the specific payer policy you are submitting claims to. Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary. The use of the PT modifier is also a Medicare rule, see information below from the WPS website.

With that being said, what I am saying is if the payer you are billing has a policy and the provider is contracted with that payer, the provider is obligated to follow the payer's policy. AMA does indeed have guidelines, but a payer may have their own rules, and if so you need to follow the payer’s rules. A lot of payers follow CMS policies and rules such as BC, OPTUM, UHC…. In regards to reaching our to your payer, the claims department will likely not be of help, However, most providers are assigned a Provider Representative that is there for the provider and staff, you should know your large provider Reps by their first name.

The key is to UNDERSTAND the specific payer policies and the rules you need to follow for each payer. The AMA may have guidelines; however, your contract with specific payers may trump those guidelines. Find-A-Code has access to Commercial Payer policies you may be interested in; it is one of our most popular tools. You will improve your bottom line and ensure compliance if you have someone managing your contracts that can identify and understand the specific rules, as well as have payer policies easily available.

Don’t forget the date of Service, was the service done before particular codes went into effect? Rules may change with payers and you are expected to keep up with them and comply with the changes on the effective date of the change. In the case of an audit, payers will look at the contracts the provider has signed with them and expect compliance with their rules.

PT Modifier 

Definition: A colorectal cancer screening test which led to a diagnostic procedure

Appropriate Usage:
When a service began as a colorectal cancer screening test and then was moved to diagnostic test due to findings during the screening. Practitioners should append the modifier to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening sigmoidoscopy HCPCS code
Append to procedure codes in the range: 10000 to 69999

Inappropriate Usage:
Do not use the Modifier PT when the service began as a diagnostic procedure
On any other procedure outside the range listed above

References:

CMS Medicare Learning Network Matters Article MM7012
Note: The Medicare policy is that the deductible is waived for all surgical procedures furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services.

WPS - Government Health Administrators- Modifier PT Fact Sheet

As per CMS MLN- MM10181:

00811 – Anesthesia Diagnostic Colo (4 base units)

00812 – Anesthesia Screening Colo (3 base units)

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 January 1, 2018, HCPCS update.

Effective for claims with dates of service on or after January 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 January 1, 2018, HCPCS update.

Effective for claims with dates of service on or after January 1, 2018, Medicare will pay claim lines with new CPT code 00811 and waive only the deductible when submitted with the PT modifier.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

HHS Proposes Significant Changes to Patient Access Rules
February 11th, 2019 - Wyn Staheli, Director of Research
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
Charging Missed Appointment Fees for Medicare Patients
February 7th, 2019 - Wyn Staheli, Director of Research
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
Q/A: Do Digital X-rays Have Their Own Codes?
February 7th, 2019 - Wyn Staheli, Director of Research
Question Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes? Answer There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...
Clinical Staff vs Healthcare Professional
February 5th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.  Physician or other qualified healthcare professionals:  Must have a State license, education training showing qualifications as well as facility privileges.  Examples of Qualified Healthcare professionals: (NOTE: this list is not all-inclusive, please refer to your payer ...
BC Advantage Now Offering Q-Pro CEUs!
February 5th, 2019 - Find-A-Code
We are excited to announce BC Advantage is now offering Q-Pro CEUs! It is now even easier to get your QPro CEUs and stay current with BC Advantage: offering news, CEUs, webinars and more. BC Advantage is the largest independent resource provider in the industry for Medical Coders, Medical Billers,...
Attestations Teaching Physicians vs Split Shared Visits
February 1st, 2019 - BC Advantage
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
Q/A: Can I Bill a Review of X-Rays?
February 1st, 2019 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ...



About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association