Wiki Consulting physician denials due to Missing AI modifier

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liz_snyder

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We are starting to get denials from Medicare for our consulting physicians that are billing the hospital admission codes since Medicare will not pay for consult codes as of January 2010. Reason for denial – “Payment already made for same/similar procedure within set time frame.” After further research we found the attached information dated June 2013 from Medicare regarding the use of the AI modifier and how it affects other physicians. We are finding that if two of our specialists provide a consult on the same DOS and the “Principal Physician of Record” did not put an AI on their E/M code for the same DOS only the first specialist will get paid and the second one will be denied with the M86 remark code. Neither one of my specialists is the “Principal Physician of Record” and my doctors are from different specialties yet we cannot get the second one paid unless we contact the “Principal Physician of Record” and ask them to reopen their claim to add an AI. We were told that without an AI modifier on an E/M code for that DOS they will pay for only one code per day no matter what specialty or office the doctor is from. This isn't just for the date of admission either. This includes all subsequent days also.

This also raises the question, what if the “Principal Physician of Record” cannot bill an E/M code for that DOS because it falls within a global period? There isn't a claim to put the AI modifier on so one doctor will get paid for that DOS and all other will be denied for services rendered. We have tried to appeal these with medical records to by pass the other physician from having to update a claim with AI modifier and claim is still denied.
Is anyone else having this issue? Anyone have any suggestions?
 

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  • 2013-06 CMS Consulting Physicians AI info.pdf
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AI modifier

I work multiple specialties. The edit in MC is build in a way that if two 99221-99223 are bill without a modifier AI of course will hit their edit as a duplicate charge. So if your admitted physician (let think an Internal Medicine) charge an adm. e/m service of 9921-99223 and your consultant charge a 99221-99223 as well it will hit the edit so the only way of bypass their edit is having the Internal Med doc. to fix their claim. If you keep doing that perhaps they will get tired of hearing from you and do the right thing. At the otherhand if for the contrary the Internal Med doc charge a 99231-99233 instead of 99221-99223 because a transfer of care, not enough element or for whatever reason and your physician charge 99221-99223 it WILL NOT hit their edit, their logic is for mod AI categories of 99221-99223 only (remember AI is only appropiate for that category 99221-99223).

Furthermore, if I have that situation having principal physician not addding AI to their service code and for real is happening frequently not once or twice I will document each time and aproach the leader (e.g. manager of Internal Medicine clinic) of their billing and coding office to address the issue.

Hope it helps, :)
 
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Multiple consults

I am running into the same issue. I have two consulting physicians from different specialties and we can get one paid but they continually deny the second consult. The payer that we have the most trouble with is Humana. The chart has the admitting physician, who we do not doing the billing for, and then we have our two consulting physicians that we do do the billing for and they will pay for one of our consulting physicians but not the other and they are two totally different specialties. We have sent in notes and done appeals and are still getting no where. I am up for any suggestions on how we can get these claims paid without having to jump through so many hoops.

Thanks:confused:
 
We do the billing for multiple specialties but they are totally different specialties and groups. I have Ortho, Renal, General Surgery, Cardiology, etc. and they are all bumping up against each other and most of the time we have no control over the admitting physician. This issue isn't just on the date of admission either. More often than not we are billing the admission code (for the consult) on a subsequent date and that is when we get most of the denials.

I also bill for a primary care physician that admits patients and I have always used the AI modifier on the admissiong code on the admit day only but the way I am reading the attached document I should be using it on all subsequent visits also. Is that correct?
If we are supposed to us AI on all subsequent visit - do I use AI modifier on my doctor's E/M visit if he is covering for the Principal Physician of Record? If I dont' it will mess up the consultants. We are coming up with more questions than answers in our office right now.
 
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Sometimes if the specialist use the same DX the 2nd submission will be denied. DX should be related to specialty and not all the same. the AI is not a mandatory modifier yet it is still considered informatiional
 
Thank you, that makes sense however sometimes we need to use the same diagnosis. For example, the admitting physician is a hospitalist and uses the most acute dx as their primary dx and reason for admission. If that dx is the reason my specialist was asked to consult, he will use the same dx as primary. This is unavoidable.
 
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