EM Coding Alert

Adopt modifier AI when there’s more than one initial care performed.

Because, as of 2010, CMS no longer pays for outpatient and inpatient consult codes and most coders refer to 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient…) as “admit” codes, coding for initial hospital consultation services is difficult. 

If you don’t use initial inpatient hospital codes very often, you may have forgotten that when CMS stopped payment for consultation codes, it provided a workaround modifier to enable a physician that admits a patient and another physician that performs initial hospital care later that day, to both be paid.

Keep reading to fully understand how to report your provider’s first encounters in the hospital with patients.

Swap Out Consult Codes with 99221-99223 (or 99231-99233)

When CMS published an MLN Matters article MM6740 in 2010, saying that consult codes (99241-99245, Office consultation for a new or established patient … and 99251-99255, Inpatient consultation for a new or established patient …) would no longer be recognized for Part B, it became obvious that they intended coders to report from the 99221-99223 range for every provider’s first hospital encounter with a patient. 

CMS’s advice was to “bill an initial hospital care code” (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) when appropriate, with the principal physician of record attaching modifier AI (Principal physician of record) to signal which physician is overseeing the patient’s inpatient care. Any other specialist seeing the patient for the first time would also submit from that code range with no modifier. The payer will know from the modifier which provider is the principal physician.

“When CMS decided to discontinue payment for consultations beginning in 2010, there had to be an alternate method for reporting consultative services,” says Maryann C. Palmeter, CPC, CENTC, director of Physician Billing Compliance at University of Florida Jacksonville Healthcare, Inc. “The AI modifier identifies the service provided by the admitting physician of record, not the consultative service. Without this capability, practices would not be reimbursed for consultative services in the inpatient environment.”

Caution: The E/M documentation requirements for the lowest level initial hospital care code (99221) is higher than the E/M documentation requirements for either 99251 or 99252. “View medical record documentation and select the appropriate initial hospital care code (99221-99223),” suggests Palmeter. 

CMS has said that if the documentation does not fulfill the requirements for the lowest level of initial visit and the physician is seeing the patient in a consultative capacity, the 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …) codes can be used. Be aware that this does not apply for the physician admitting the patient (and using the AI modifier). If your physician is the admitting provider and the documentation does not fulfill the 99221, then you must use the 99499 (Unlisted evaluation and management service).

Set the Stage at Admission to Who is the Principal

Modifier AI is for information only so even if you don’t attach it to the E/M service code, your physician will get paid. Even if a second specialist performs face-to-face initial care later in the same day as the admitting physician and submits her claim first, your physician will get paid when he attaches AI to the 99221.

Example: “A family physician (FP) admits a Medicare patient to the hospital with chest pains, shortness of breath, and complications related to the patient’s diabetes, congestive heart failure, and chronic obstructive pulmonary disease,” provides Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Kan. “On the day of admission, the FP sees the patient in the hospital and provides a comprehensive history, comprehensive examination, and medical decision making of high complexity. The FP is listed in the hospital chart and records as the principal physician of record. In this example, it would be appropriate for the FP to report 99223 with modifier AI appended.”

Prepare for Non-Admitting Doctors

There is confusion among coders as whether they should use the initial hospital care codes or the subsequent visit (99231-99233) for non-admitting doctors. Even some coding experts are feeding the fire by advising physician coders to use the subsequent hospital care codes. However, according to CMS, 99221-99223 are the correct codes to use when your provider sees a patient for the first time in the hospital, even if he is not the admitting physician. 

“In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs who perform an initial evaluation may bill an initial hospital care visit code (CPT® code 99221 – 99223) or nursing facility care visit code (CPT® 99304 – 99306), where appropriate,” advises CMS in MLN Matters article MM6740.

Pitfall: Some of the confusion stems from the fact that many coders refer to 99221-99223 as “admit” codes, when in reality they are the initial or first visit the provider has with the patient. There is no code specifically for the admission to inpatient status. 

Remember that only the principal physician can use the AI modifier. If more than one provider attaches that modifier, the one that submitted first will get paid as the principal. But again, it is used for informational purposes only. The consultant shouldn’t submit his claim with it.

Example: Let’s say the FP in the above scenario requests a consultation from a cardiologist related to the patient’s chest pain and congestive heart failure (CHF). “The cardiologist sees the patient, takes a detailed history and exam related to the patient’s heart problems, and arrives at some conclusions and recommendations that involve medical decision making of moderate complexity,” says Moore. “The cardiologist reports his findings/opinion/advice to the FP, who is maintaining ongoing management of the patient’s conditions. In this example, the cardiologist cannot report an inpatient consultation code (99251-99255), because Medicare no longer recognizes those codes for payment purposes. The cardiologist may consider reporting 99221 for the encounter, since it is his first encounter with the patient in the inpatient setting; however, he should not append modifier AI to 99221 if he does, because he is not the principal physician of record for the patient. The FP maintains that role.”