Wiki Humana interpreting AI modifier erroneously

[heartyoga]

Our physician has seen this patient as a consult in the hospital. The hospitalist billed 99223-AI and we billed 99223 as a consult. Humana denied saying "According to CMS Policy, only the admitting physician should bill initial hospital care E/M code and should bill with appropriate modifier to denote the service rendered by the admitting provider. Code 99233-AI was billed under claim xxx on the same date of service. Review of records support that the denied initial hospital E/M service was rendered by the Consulting provider."

Our doctor is prompt and diligent and sees the patients as soon as he is consulted. If this is the case, he would have to see patients the next day which is not sound medical practice and lengthens the stay.

Any suggestions on how to clarify this with Humana? It seems like they are not interpreting the CMS policy the way it was meant to be.

Thanks for your inputs.

 

[thomas7331]

They are clearly incorrect here. I would appeal with a copy of this CMS publication:

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/mm6740.pdf

Highlight or point out to them these sections from page three:

"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.

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."

 

[heartyoga]

Thanks

Thanks for your clarification.