The implementation of health care reform regulations has begun with a significant change involving preventive services. The Patient Protection and Affordable Care Act (PPACA) requires all health care insurance plans to begin covering preventive services and immunizations without any cost-sharing, i.e., they must provide first-dollar-coverage for specified preventive services. The timing of implementing these changes is dependent on when health insurance plans renew or change. The regulations specify that plans cannot impose cost-sharing requirements, such as co-pays, coinsurance or deductibles with respect to specified preventive services, when preventive services are billed separately. When these services are part of an office visit, the visit may not require cost-sharing if the primary reason for the visit is to receive preventive services. However, cost-sharing is permitted when the office visit and covered preventive services are billed separately and the primary purpose of the visit is not delivery of the covered preventive services.
In addition, insurance plans are permitted to impose cost-sharing (or choose not to provide coverage) for recommended preventive services if they are provided out-of-network. Not all services that some clinicians consider preventive are included in the law. For preventive services not covered in the statute and regulations, plans may require cost-sharing. The new mandate may also affect payer coverage or payment policies for services listed in the Counseling Risk Factor Reduction and Behavior Change Intervention section of CPT (99401–99429).
For a comprehensive list of recommendations and guidelines covered by the final regulations, please visit www.healthcare.gov/center/regulations/prevention/recommendations.html.
In response to the PPACA requirement, CPT Modifier 33 was created to allow providers to notify insurance payers that the service was preventive under applicable laws and patient cost-sharing does not apply. The modifier assists in the identification of preventive services in payer-processing systems. It indicates when it is appropriate to waive the deductible associated with copay/coinsurance and may be used when a service was initiated as a preventive service, but then was converted to a therapeutic service.
The complete description for Modifier 33 is:
Modifier 33, Preventive Service: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending Modifier 33 to the service. For separately reported services specifically identified as preventive, the modifier should not be used.
CPT Modifier 33 is applicable for the identification of preventive services without cost-sharing in four categories. For an explanation of those categories, please read the following article by the American Medical Association.
Using CPT Modifier 33 will be an important function for all family physicians as they provide preventive services to patients and collect (or do not collect) copayments, coinsurances and deductibles from patients.