Understanding PT Modifier in Medical Billing

It can be overwhelming to keep track of all the medical coding billing guidelines, such as accurate diagnosis and procedural code selection, appropriate modifier usage, documentation requirements, and whatnot. 

If you are a healthcare facility or a physician conducting colorectal screening, you may have encountered the modifier PT. But do you know when and how to append it and what billing rules you must comply with to ensure timely payment?

If you lack knowledge in any areas related to this modifier’s use, we recommend you read this guide till the end.

PT Modifier – Description

It is a level II or HCPCS modifier. Centers for Medicare and Medicaid Services (CMS) creates level II modifiers, similar to HCPCS codes, that are either comprised of two letters or a number and a letter. These modifiers were introduced to help billers provide additional details about a rendered procedure that level I modifiers or CPT modifiers (two-digit numeric codes) are unable to describe effectively.

You may append the PT modifier to highlight to Medicare that a colorectal screening service transitioned into a therapeutic or diagnostic service so that the payer covers the service without any deductible or co-pay and coinsurance.

Scenarios Where a PT Modifier is Applicable

We understand how overwhelming it could be to determine whether a particular situation demands modifier usage or not to ensure accurate reimbursements. Thus, discussed below are some practical examples that will give an idea about what scenarios during screening services call for the use of this modifier. 

So, without further ado, let’s get started!

Colonoscopy Screening Leading to Polypectomy

Let’s say a patient comes for a routine screening colonoscopy. However, during the procedure, the healthcare provider identified multiple small polyps. 

Thus, while reporting the colonoscopy code, the physician will append the PT modifier to indicate to the payer that the screening service converted into polypectomy (a therapeutic intervention) due to the unexpected detection of multiple polyps.

Hemostasis During Sigmoidoscopy Screening 

Assume a patient undergoes a flexible sigmoidoscopy screening. However, during the procedure, the physician encountered minor bleeding. As a result, the healthcare practitioner performs electrocautery to achieve hemostasis. 

Thus, modifier PT is applicable because the sigmoidoscopy transitioned from screening to a diagnostic/therapeutic procedure to address unexpected bleeding.

Barium Enema Screening Converted to Diagnostic Investigation 

Consider a patient who comes for a routine barium anemia screening. However, during the screening, the radiologist discovers a suspicious area in the descending colon. 

Since the barium enema initially began as a screening procedure and later transitioned into a diagnostic investigation due to the unexpected finding, the PT modifier will apply here.

Modifier PT – Billing Guidelines

Each modifier has some specific billing requirements that you must follow to avoid potential denials and payment delays. Thus, in this section of the blog, we will look into some key rules while reporting procedures with the PT modifier.

Append Only to Medicare Claims

This modifier applies only to Medicare beneficiaries. Do not use it if the patient is enrolled in a commercial insurance plan.

Append to Highlight the Service Conversion

When the procedure started as a colorectal screening but transitioned into a diagnostic or therapeutic service due to unexpected findings, use modifier PT to indicate this to the insurance payer.

Ensure Appropriate Procedural Coding

Note that you must use the correct codes for the intended screening service as well as the converted diagnostic procedure.

Append to the Diagnostic/Therapeutic Procedure Code 

Always append the modifier PT to the diagnostic procedural code. Do not append it to the CPT code for screening colonoscopy or sigmoidoscopy, as it will result in a claim denial.

Append with the Correct Surgery CPT Codes 

You can add this modifier to the surgical procedures CPT codes in the range 10000-69999 and HCPCS code G0500.

Append with the Correct Anesthesia Service Codes 

You can also append this modifier to the appropriate anesthesia service codes associated with the surgical procedures in the coding range 10000-69999 and G0500.

Do Not Use if the Original Service was Diagnostic 

Avoid using the PT modifier when the service was originally started as a diagnostic procedure.

Maintain Comprehensive Documentation

Ensure comprehensive and accurate documentation. Record the initial screening intent, i.e., your documentation must explicitly state that the procedure barium enema, sigmoidoscopy, or colonoscopy) was begun as a screening investigation for colorectal cancer.

Besides, include the unexpected findings that necessitated the transition of the screening procedure to therapeutic or diagnostic. These unanticipated scenarios can be polyp detection, suspicious lesions, bleeding, etc. 

Based on the findings, what subsequent procedures were performed? Document and code these procedures accurately and ensure your documentation establishes the medical necessity and appropriateness of the rendered subsequent care service.

Summary

With that said, let’s quickly revisit what we discussed in this guide! We explained what level II or HCPCS modifiers are, how they differ from level I or CPT modifiers, and what the PT modifier indicates to the payer, i.e., a colorectal screening service converted to a therapeutic/diagnostic service.

We shared some examples where this modifier is applicable and discussed the billing guidelines that you must follow while appending this modifier. We hope these details will help you ensure the appropriate usage of this modifier. However, if you struggle to navigate the complex medical billing landscape, you can partner with our billing specialists at MediBillMD to experience a steady cash flow and a healthier revenue cycle.

Frequently Asked Questions