Part B Insider (Multispecialty) Coding Alert

Published on Wed May 21, 2014 PDF

The admit rules changed with the introduction of modifier AI.

If your coding education took place prior to 2010, you might still be under the impression that only one physician can charge Medicare for initial hospital care—but if you fall under the spell of this common myth, you could be losing money.

Myth: Your physician admits a patient to the hospital and another specialist performs initial hospital care later that day. The other specialist submits his claim first, which means that only he will get paid for the admission—and your doctor won’t, right?

Not so fast.

Reality: It’s true that only one physician can charge for a patient’s admission, but in reality, both doctors can charge for initial hospital care to reflect their first services with the patient. In the example above, your physician should append 99221-99223 (Initial hospital care…) with modifier AI (Principal physician of record) to show that he admitted the patient. The other doctor will charge for his services with a code from the same series but with no modifier to report his first visit with the patient.

Background: Before 2010, only the admitting physician reported initial hospital care codes, and specialists who saw the patient separately often billed inpatient consultations. Since CMS no longer recognizes the consultation codes, multiple physicians may report initial hospital care during a patient’s visit.

As most practices are aware, CMS announced its decision to no longer accept consultation codes in 2010. The agency released MLN Matters article 6740 to quell confusion, 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.

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.