Modifier Coding Alert

Published on Wed Jan 28, 2015 PDF

Informational modifiers can clarify who should be paid when there are multiple professionals.

If you haven’t properly identified the rendering provider on your claim, your payer may reject some of your claims regardless of proper procedure coding. Knowing the “A” modifiers will give your claims that nudge they need to help get your payer’s approval.

Continue reading to learn which of the eight “A” modifiers identifies your provider and keeps your claim afloat.

Being More Specific Strengthens Claims

HCPCS modifiers AE (Registered dietician), AF (Specialty physician), AG (Primary Physician), AH (Clinical psychologist), AI (Principal physician of record), AJ (Clinical social worker), AK (Non-participating physician), and AM (Physician, team member service) reveal the license level of the rendering provider to inform the payer that the provider has the qualifications to perform the procedure or service and therefore strengthening your claim. Some payers require you submit some of these modifiers with specific procedure or service codes.

In general: Critical access hospitals (CAH) must use modifiers AE, AH, and AK for services that registered dietitians, clinical psychologists, and non-participating physicians provide.

Here are examples of guidance from two payers — Novitas and Palmetto GBA — for each of the eight modifiers. 

Modifier AE: Registered Dietician

When you report services rendered in a critical access hospital (CAH) by a nutrition professional/registered dietitian, you must use modifier AE on the claim.

Guidelines from Novitas Solutions and Palmetto GBA tell you to submit modifier AE with claims for medical nutrition therapy (MNT) and diabetes self-management training (DSMT) claims. Use this modifier with HCPCS codes G0108-G0109 (Diabetes outpatient self-management training services, individual, …) and G0270-G0271 (Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease, …), and CPT® codes 97802-97804 (Medical nutrition therapy; …).

Modifier AF: Specialty Physician

Your clinic should attach modifier AF when a psychiatrist, a physician having the approval of OMH, or a psychiatric nurse practitioner spends at least 15 minutes participating in a service or procedure given by another physician or when a psychiatrist/nurse practitioner in psychiatry (NPP) provides a service or procedure. When a psychiatrist or an NPP runs a group session or when she participates in the group session for at least 15 minutes, you can also attach modifier AF for each patient in the group.

Novitas and Palmetto recognize modifier AF as informational and you may submit AF with all HCPCS and CPT® codes.

Modifier AG: Primary Physician

Use modifier AG to identify the primary surgeon when there’s more than one surgeon providing a service on the same patient. You can also use AG if there is more than one primary surgeon performing separate services on the same date of service, in different specialty areas.

Exception: The California Department of Health Care Services says you can no longer attach modifier AG to 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants). If you do, payers will deny the claim.

Novitas and Palmetto recognize modifier AG as informational and you may submit AG with all HCPCS and CPT® codes.

Modifier AH: Clinical Psychologist

Use modifiers AH and AJ on psychiatry claims involving therapeutic procedures to communicate that a clinical psychologist and/or clinical social worker performed the service(s).

Novitas allows the use of modifier AH on submissions of diagnostic psychological tests and therapeutic psychotherapy performed by a clinical psychologist. Palmetto doesn’t require the provider to be a clinical psychologist.

“Contractors shall not require the submission of modifier AJ for clinical social workers (CSWs) or modifier AH for clinical psychologists (CPs),” states CMS in Transmittal 2656 found on www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2656CP.pdf

Modifier AI: Principal Physician of Record

Palmetto GBA says you can use modifier AI with 99221-99223 (Initial hospital care, per day, …) and 99304-99306 (Initial nursing facility care, per day, …). They recognize AI as identifying the primary physician providing care for a patient, differentiating it from all other possible physicians furnishing specialty care.

Principal physician is also known as the admitting physician, and you will attach AI to the applicable admission code to identify that physician from other healthcare professionals involved in the care of the patient. Keep key points for using this modifier in mind:

• It’s informational only
• For inpatient services
• Only use for the physician who is responsible for the overall care of the patient
• Attach to admitting physician’s initial hospital visit code.
• It is not a required modifier at this point either.

Modifier AJ: Clinical Social Worker

Novitas and Palmetto GBA instruct you to submit modifier AJ with diagnostic psychological tests and therapeutic psychotherapy performed by a CSW. Palmetto says a CSW doesn’t have to perform the services but Novitas and Palmetto both agree that AJ must be on assigned claims, where the physician accepts the amount allowed by Medicare to be the full payment.

Modifier AK: Non-Participating Physician

If you code for a critical access hospital, you need to use modifier AK on claims for services rendered by physicians that don’t participate in a payer’s network.

Palmetto GBA recognizes modifier AK as informational and you may submit it with all HCPCS and CPT® codes.

Modifier AM: Physician, Team Member Service

Medicare requires that you use modifier AM when reporting patient visits made by physicians, physician assistants, nurse practitioners, and certified nurse specialists to nursing facilities and skilled nursing facilities.

Palmetto GBA states that you may not submit modifier AM on a Medicare Part B claim. Novitas allow you to submit modifier AM on a Medicare Part B claim.