What is the PT Modifier in Medical Billing?

Medical billing is a complex process. Sometimes, even trained billers with decades of experience get confused due to the sheer complexity of codes and the required documentation. This is a common scenario in colorectal cancer screenings. How? Well, sometimes a simple screening colonoscopy converts into a diagnostic or therapeutic procedure. In this case, deciding what to bill can become complicated. 

To solve this issue, Medicare recommends the use of a PT modifier. And that’s the topic of this guide. We will understand what this modifier is, when to use it, and how to use it effectively in your claims. So, let’s start. 

PT Modifier – Description

This modifier is defined as:

“Colorectal cancer screening test; converted to diagnostic test or other procedure.”

The PT modifier is a Healthcare Common Procedure Coding System (HCPCS) Level II modifier. The important thing to note is that it is only for Medicare claims. You cannot use it for other public or private insurance companies. Other payers use modifier 33 to achieve the same goal. 

Billers use PT to tell Medicare that a service began as a routine screening for colorectal cancer but turned into a diagnostic or therapeutic procedure because of what was found during the exam. If such a situation occurs, it is essential to append this modifier to the claim. Otherwise, the payer will see the procedure purely as a diagnostic surgery and will incorrectly apply a deductible to the patient’s account. 

PT on the claim tells Medicare to waive the Part B deductible amount for a screening colonoscopy that turns diagnostic. 

PT Modifier – Usage Examples

To make things clear, let’s look at a couple of real-world scenarios in which this modifier can be used.

Screening Colonoscopy with Polypectomy

Suppose a patient comes to a practice for a routine screening colonoscopy. She has no symptoms (no bleeding, pain, or GI history). However, during the colonoscopy, the physician finds a polyp in the sigmoid colon and removes it using the snare technique.

The patient is a Medicare beneficiary. So, how would the billing department handle this? Well, they can simply use the appropriate procedure code, e.g., CPT 45385 (colonoscopy with removal of tumor, polyp, or other lesion by snare technique) and append modifier PT to it. 

Screening Colonoscopy with Biopsy

For our last scenario, suppose a patient is undergoing a routine screening colonoscopy. However, during the procedure, the physician finds abnormal tissue growth that does not look like a polyp. The physician suspects that it might be cancerous tissue. So, in the same procedure, he performs a biopsy with cold biopsy forceps.

In this scenario, the billing department can use the CPT 45380 with the modifier PT to bill the procedure. 

Accurate Usage Guidelines for PT Modifier

The definition gives you a basic idea of what PT is. But to practically use it in your billing, you must know the following essential guidelines and billing limitations.

Append to the Procedure Code

Never append modifier PT to the screening G-codes (G0105 or G0121). If a screening turns diagnostic, you stop using the G-code entirely. You bill the CPT code that describes what was actually done (e.g., 45380, 45384, or 45385). You append the PT modifier to that CPT code.

Understand the Medicare Coinsurance Phase-In

For years, patients were frustrated that while the PT modifier waived their deductible, they were still hit with a 20% coinsurance for the surgery. Congress passed legislation to fix this “loophole”.

If a screening results in a procedure (and you use this modifier), the patient’s coinsurance responsibility is being phased out over time. According to Noridian’s CRC screening guidelines and CMS Change Request MM12656, the schedule is as follows:

• CY 2023 through 2026: The patient pays 15% coinsurance.
• CY 2027 through 2029: The patient pays 10% coinsurance.
• CY 2030 and beyond: The patient pays 0% coinsurance.

This means that until 2030, even with modifier PT correctly applied, Medicare patients may still receive a small bill.

Use with Anesthesia Services

The PT modifier also applies to anesthesia services provided during these procedures. If a standard screening colonoscopy becomes a surgical procedure, the anesthesia provider should also report their service with this modifier.

Final Thoughts 

That’s all for this guide. Let’s do a quick recap of the essential points in case you missed anything.

• Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or therapeutic procedure.
• For proper reimbursement, you must provide detailed documentation with your claims. 
• Append the modifier to the CPT code, not the G code. 

We understand that medical billing can be frustrating, especially when you are facing frequent denials. Hence, it is better to get outsourced medical billing and coding services and let professionals handle the intricacies. Many third-party companies, like NeuraBill, offer services with guaranteed results.

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