Thursday, July 28, 2016

Modifier question - Hospice , AI modifier, GW modifier definition

What modifier do i use for Hospice

There are two modifiers to be used for Hospice care. Those based on the service which was provided. Those are GW and GV.

Let us see the definition of hospices modifiers and its usage.

    GV - Attending physician not employed or paid under agreement by the patient's hospice provider.
    GW - Service not related to the hospice patient's terminal condition

Modifiers should be printed in CMS form field 24D. We have to append GV or GW modifiers only when patients are enrolled in Hospice Care.  

Use hospices modifier when the services was provided by the physician are billed to Medicare Part B.
We have to use Q5 or Q6 instead of GV or GW if a substitute or locum tenens physician provided services.


AI modifier Definition -  Principal Physician of Record


AI modifier will be used by the admitting or attending physician who taking care of the patient while in an inpatient or nursing facility setting, 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.

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. 

Instructions

This modifier distinguishes the Principal Physician who oversees patient's care when performing evaluation and management (E/M) services and is only appended to an appropriate E/M code by that physician. It is imperative, so that other specialties may bill their claims for the same E/M code and not receive denials.

Correct Use

    Append to initial/subsequent E/M codes only
        99221 – 99223 (Hospital-Initial)
        99231 – 99233 (Hospital-Subsequent)
        99291 (Critical Care)
        99304 – 99306 (SNF-Initial)
        99307 – 99310 (SNF-Subsequent)
    Only principal physician of record appends to E/M code

Incorrect Use

    Inappropriate for another physician to append (primary or specialty)

Claim Coding Example

Treatment Description


CPT/Modifier

Dr. x Bill


Principal physician of record initial inpatient visit


99222 AI

Dr. y  Bill

Another specialty; initial inpatient visit, same day


99222

AI Modifier usage 

• 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.

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. 

The principal physician of record shall append modifier “-AI” in addition to the initial visit code. The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and nursing home visit codes. Contractors shall take no action if the “-AI” modifier is billed with codes that fall outside of the correct range 99221-99223 and 99304-99306. It is not necessary to reject claims that include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes such as the subsequent care codes or outpatient codes. 





What is modifier GW

GW modifier has to be use only for Hospice care. When a provider of service performs services not related to the hospice diagnosis. 


Modifier GW

Condition not related to the patient's terminal condition

Instructions

    Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient's terminal condition.
    All providers must submit this modifier when this condition applies.

Claim Coding Example

Patient is on hospice for congestive heart failure and goes to the office for a toe nail trim.  The procedure is unrelated. The GW modifier should be added to the CPT for the toe nail trim.

Modifier 57 use with example


Modifier 57 is appended to Evaluation and Management services (E/M) in initial decision to perform surgery either the day before a major surgery. It applies 90 days Global period.
How to classify Global period
There are 3 type of global surgical period based on the number of post-operative days.

Zero day Post-operative period

No pre-operative period
No post-operative days
Visit on day of procedure is generally not payable as a separate service

10 Day Post=operative period
No pre-operative period
Visit on day of the procedure is generally not payable as a separate service
Total global period is 11 days. Count the day of the surgery and 1o days of the surgery.

90-days Post - operative Period

One day pre-operative included


Day of the procedure is generally not payable as separate service
Total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery and the 90 days immediately following the day of surgery.

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