Modifier Coding Alert

Question: My physician’s office is having trouble getting reimbursed for charges on hospital patients when we have a specialist who also sees the patient. I’m adding modifier AI to the admitting physician’s claim and it’s being denied.

The admitting physician admits the patient for an abdominal pain and uses 99221-99223. The surgeon sees the patient to determine if surgery is needed and charges a 99221. This is the surgeon’s initial visit with the patient.

Medicare is only paying for one claim because they say two admission services are being billed on the same day. We have tried billing with and without the AI modifier.

What can I do to get both physicians reimbursed?

Washington Subscriber

Answer: You are correct that you should append 99221-99223 (Initial hospital care) with modifier AI (Principal physician of record) for the physician who admitted the patient. You are also correct to charge for the initial hospital care with no modifier for your surgeon’s first visit with the patient.

Background: In the past, only the admitting physician reported initial hospital care codes, and specialists who saw the patient separately often billed inpatient consultations. Since Medicare (CMS) no longer recognizes the consultation codes, multiple physicians may report initial hospital care during a patient’s visit.

CMS announced their decision to no longer accept consultation codes in January 2010. They released MLN Matters article 6740 which states: “The principal physician of record will append modifier “AI” Principal Physician of Record, to the E/M code when billed. This modifier will identify the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed.”

• You need to remember the following points about modifier AI:
  
• You’ll use it as information only
  
• You’ll only use it for inpatient services
  
• You can only use it for the physician who is responsible for the overall care of the patient
  
• You should append it to the admitting physician’s initial hospital visit code.
  

Depending on your payer, they won’t wait for the claim with the appended AI modifier before paying the initial hospital care claims submitted by other specialists. The modifier is informational only so payment shouldn’t be impacted even if you forget to add the AI modifier.

Remember: Medicare doesn’t accept consultation codes but private payers may if the documentation meets consultation coding requirements. If your payer does accept consult codes, those codes may be correct instead of 99221-99223.

Watch for: In the past, there was a typo on the inside cover of the AMA CPT® manual that listed A1. The correct modifier is the letter A and the letter I. Not letter A with the number 1. A correction to the manual was published at www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt/errata.page.

Best bet: If you’re still having trouble with the claim, talk to your Medicare contractor and ask them what rules you should follow. When you have a patient that isn’t a Medicare beneficiary, your payer may not require the modifier. Again, talk to your payer because the rules can be payer specific.