Annie Posted Thu 12th of October, 2017 13:00:01 PM
I know that the AI modifier should be used on the initial inpatient charge to show the attending or Physician on Record, but lately I have been getting denials from Medicare for critical care charges in the middle of the patient stay because of a consult charge from another provider. Do I need to use the AI modifier everyday of the visit, especially if my level change, but it still the same doctor? example: Patient stay is 4 days and Hospitalist admit patient using 99222, and I use the AI modifier on the initial charge, but on day 3 I use a critical care code 99291. There is a consulting doctor seeing the patient everyday and entering E and M charges also. My initial charge and subsequent are being paid but the critical care is being denied: for 99291 done on the same day as a E and M, and the E and M was a consult.
SuperCoder Answered Fri 13th of October, 2017 03:47:24 AM
Modifier AI is for principal physician of record. Append this modifier to the initial hospital and nursing home visit codes to show that the provider is responsible for the overall care of the patient. This modifier indicates the service by the admitting or attending provider who oversees the patient’s care, as distinct from other providers who may furnish specialty care. The principal provider of record shall append modifier AI to the initial visit code. The primary purpose of this modifier is to identify the principal provider of record on the initial hospital and nursing home visit codes. Remember that modifier AI is for inpatient use only, not for outpatient evaluation and management, or E/M, codes. Modifier AI is informational only and does not impact the payment.
For the initial hospital visit use code from CPT code range 99221-99223, subsequent hospital care from CPT code range 99231-99233 (for 2nd and 3rd day according to your stay example of 4 days) and CPT 99238/99239 for hospital discharge.
Medicare restricts it to the E/M being only before the critical care time and it needs the 25 modifier, but Medicare says that they will automatically deny in order to get documentation on appeal.
Critical care cannot be billed with hospital inpatient visit when services are provided for the same disease for which patient was admitted, because admitting team has to take care of that condition of the patient. On the other hand, if patient developed some other condition(s) for which critical care is needed then it can be billed.
Whereas, consulting physician can bill for inpatient consultation.