Wiki Modifier needed for inpatient

[debellis59]

Hi Everyone:

We have problems with hospitalists and with specialists seeing patients the same day in the hospital. The insurance is requiring a modifier to differentiate the different providers, but 25 is not working. We've requested help from this insurance (state insurance) and they said they're sending the provider manual, but so far nothing.

Does anyone know what modifier would differentiate between provider specialties in the inpatient setting so we can get paid? The state says they'll gladly pay, but that we need the correct modifier. I'm stymied.

Any help would be appreciated.

Thank you.

Deb

 

[rstroup]

Hi Deb,

I was a biller for some years at a surgery clinic and this was a common issue with our surgeons who would be consulted in the hospital. It is actually the hospitalist that needs to append the modifier. They need to use modifier AI to indicate they are the principal physician.

--
Ryan Stroup, CPC

 

[csperoni]

By coding rules, different providers of different specialties should not require a modifier for that reason alone. There is a modifier -AI for the initial inpatient visit which goes on the admitting physician's claim. Other than that, this must be a carrier rule/guideline. Perhaps their website provides the information required?

If the providers are part of the same group, it is possible they are credentialed as the same specialty leading to this issue. Most payors use taxonomy codes. Some (like Medicare) use a much shorter list. Per Medicare, a general obgyn and a urogynecologist are the same exact 2 digit specialty code. So if a general obgyn sees the patient and then refers to a urogynecologist within the same large healthcare organization who sees the patient the same day, some insurances will not pay both.

 

[TThivierge]

Hi Debellis59,
I suggest trying these modifiers to define the different clinical providers. Check it in the HCPCS manual Appendix 2. The modifiers you may seeking could be ... AE Register dietician,, AF Specialty Physician , AG Principal physician, AH Clinical Psychologist, AJ Clinical Social Worker and GF special non physician such as ,NP, PA CRNA. Also notice if patient is in MH group therapy modifier called HO probably linked with CPT 90853. To be sure I would check with the payer first.
I hope helped you
Lady T