Coding rules for modifiers 32 and 33 with cpt codes in medical billing and coding

Coding Rules for Modifiers 32 and 33 with CPT Codes in Medical Billing and Coding

There are a couple of modifiers in medical coding that are very rarely used. Two such modifiers are 32 and 33. These modifiers can only be used when there is appropriate documentation supporting the case. Here are some pointers on how to use codes 32 and 33: When should Modifier 32 be used?

Modifier 32 is used only whenever a service has to be extended to a third party entity or in the case of Worker’s Compensation or some other such official entity. However, modifier 32 may never be used when the patient wishes to seek a second opinion from a different doctor. Even in the case of a family member of the patient or a doctor seeking the second opinion, this modifier cannot be used.

The modifier 32 can only be used upon the service being mandated specifically. It may be an insurer seeking a report regarding the independent evaluation about the claim report filed by one of the workers.

The insurer also has the right to seek a second opinion regarding the patient’s condition even before treatment or testing can commence. This is another occasion when modifier 32 can be used. However, as mentioned earlier, neither the patient nor any family member of the patient has the right to seek a second opinion or use the modifier 32 for that purpose.

Modifier 32 cannot also be used while seeking consultation from another doctor, or even when a physician goes for a patient evaluation with regards to medical clearance that may be required before a procedure can commence. Moreover, Medicare never accepts modifier 32, and no payment can be expected to be made for any service that is requested by any other provider. Modifier 32 is always used only for commercial or private payers. It is up to the third-party payer to waive any deductibles, which it usually does, along with the co-payment for the concerned patient, and the third-party payer usually makes a 100% payment for the service in such cases.

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When should Modifier 33 be used?

Modifier 32 was included by the American Medical Association (AMA) as a specific response to the Patient Protection and Affordable Care Act (PPACA). The act stipulates that all health insurers need to cover preventive services and immunizations on their own, without seeking or resorting to any sort of cost sharing options. Modifier 33 is specifically meant to identify such preventive services that are bereft of any specific CPT code. The modifier also allows the payer to take the initiative to waive all deductibles associated with co-payment or co-insurance. The modifier 33 may be used while identifying any preventive service that may have started off with a mere diagnosis, but may have later called for a more detailed therapeutic service.

U.S. Preventive Services Task Forces (USPSTF) has graded preventive services as grade A and B: Grade A: This includes services that have a high certainty regarding substantial net benefits.

Grade B: This includes services that have high certainty ranging from moderate to substantial net benefits.  

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It includes routine immunizations for kids, adolescents and adults, which are recommended by the Advisory Committee on Immunization Practices for Disease Control and Prevention It also includes preventive care and other screenings specifically for children, which are recommended by the American Academy of Pediatrics or Bright Futures, Newborn Testing (American College of Medical Genetics) as stipulated by the Health Resources and Services Administration It includes preventive services extended for women, which haven’t been included in the recommendations of the Task Force. They are included in the comprehensive guidelines stipulated by the Health Resources and Services Administration

Do remember that modifier 33 cannot be used with Medicare insurance, and it can only be used with commercial or private payers. Medicare never accepts modifier 33.

Modifier 33 may also be used when a patient is provided with multiple preventive Medical Billing Services by his or her physician the same day, where the modifier 33 is used to describe the preventive services carried out for the particular day.

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