Definition – Principal Physician of Record:  Effective for dates of service on or after January 1, 2010, modifier AI should be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier AI in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed.

Note: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes.

Billing and Coding Guidelines

• 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

• However, claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.

• For patients receiving hospital outpatient observation services who are admitted to the hospital as inpatients on the same date, the physician should report only the initial hospital care services codes (codes 99221 – 99223). Medicare will pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital care code (i.e., code 99221) for the initial hospital admission. Medicare will pay the office visit as billed and the Level 1 initial hospital care code. The principal physician of record, as previously noted, must append the “-AI” modifier to the claim with the initial hospital care code.

• In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.

• 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.

• However, claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.

• For patients receiving hospital outpatient observation services who are admitted to the hospital as inpatients on the same date, the physician should report only the initial hospital care services codes (codes 99221 – 99223).

Medicare will pay for an initial hospital care service if a physician sees a patient in the emergency room and decides to admit the person to the hospital. When a physician performs a visit that meets the definition of a Level 5 office visit several days prior to an admission and on the day of admission performs less than a comprehensive history and physical, he or she should report the office visit that reflects the services furnished and also report the lowest level initial hospital  are code (i.e., code 99221) for the initial hospital admission. Medicare will pay the office visit as billed and the Level 1 initial hospital care code. The principal physician of record, as previously noted, must append the “-AI” modifier to the claim with the initial hospital care code.


Should the admitting physician submit HCPCS modifier AI (Principal Physician of Record) when there is no other physician submitting an initial hospital or nursing home visit code?

Answer:
Yes, HCPCS modifier AI must be submitted by the admitting physician for the initial hospital or nursing home visit.

Evaluation and Management (E/M)

AI Principal Physician of Record: Effective for dates of service on or after January 1, 2010, modifier AI should be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier AI in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level
performed.

Note: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes.

Q. Will appending modifier “-A1”(Dressing for one wound) instead of the appropriate modifier “-AI”(Principal physician of record) to the CPT code for an initial hospital or nursing home E/M service furnished by the principal physician of record affect payment to the provider for that service?

A. Because modifier “-AI” (not modifier “-A1”) is the appropriate modifier to identify an initial hospital or nursing home E/M service by the patient’s principal physician of record, payment to the provider for the E/M service could be affected. Some Medicare contractors may reject an E/M code reported with modifier “-A1” as an invalid procedure code/modifier combination and, therefore, payment for the E/M service would not be made. In that case, the provider should submit a corrected claim reporting modifier “-AI” appended to the E/M code. If an E/M code with modifier “-A1” appended has already been submitted and paid, the provider does not need to submit a corrected claim but should report the appropriate modifier “-AI” on future claims for initial hospital or nursing home E/M services when the E/M service is furnished by the principal physician of record. Providers should contact their Medicare contractor for further assistance if necessary.


Q. Do admitting physicians still get paid if they do not report the modifier “-AI?”

A. Yes, the use of the modifier is for informational purposes only.


Q. The transmittal, “Revisions to Consultation Services Payment Policy” (Transmittal # R1875CP, also referred to as CR 6740), indicates that the CPT consultation codes are ‘not valid for Medicare.’ It also states Medicare uses a different code to report the service. However, the MLN Matters® article directed to providers states the consult codes are ‘non-covered

A. The question refers to the following passage in the original MLN Matters® article:

Physicians who bill a consultation after January 1, 2010 will have the claim returned with a message indicating that Medicare uses another code for the service. The physician must bill another code for the service and may not bill the patient for a non-covered service.

MODIFIER AI QUICK GUIDE

Definition: Principal Physician of Record

Medicare will allow services when a provider uses this modifier inappropriately on an office or other outpatient service.

Medicare will allow services when someone other than the principal physician of record uses this modifier.

Medicare can allow services provided by a physician called in to see the patient even though the principal physician of record does not append this modifier or has not yet submitted a claim to Medicare.

Documentation Requirement: The patient’s medical record will indicate the physician overseeing the patient’s care in an inpatient or nursing facility setting.

Unassigned Claim: The use of the modifier does not change the processing of unassigned claims.

Appropriate Usage:

To identify the admitting or attending physician

who oversees the patient’s care while in an inpatient or nursing facility setting

Appended to the initial inpatient hospital visit procedure code

Appended to the initial nursing facility procedure code

Valid for services January 1, 2010 and after


Consultation Code Update

UnitedHealthcare is aware of and has reviewed the Centers for Medicare and Medicaid Services’ (CMS) decision as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255.

In summary, CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).

Per CMS, a physician who sees a patient in the hospital should bill an “initial hospital care” code (99221-99223) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial hospital service allowing the Medicare Administrative Contractor (MAC) to differentiate between the admitting physician and other physicians providing care. All physicians should use the subsequent hospital care codes (99231-99233) for their follow-up care.

Likewise, per CMS, a physician who sees a patient in a skilled nursing facility should bill an “initial nursing facility care” code (99304-99306) for the first visit for Medicare claims. The admitting physician will add modifier AI to their initial nursing facility care service, allowing the MAC to identify the physician as the admitting physician of record who is overseeing the patient’s care. All physicians should use the subsequent nursing facility care codes (99307-99310) for their follow-up care.