Showing posts with label AI modifier. Show all posts
Showing posts with label AI modifier. Show all posts

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.


Services related to a Hospice terminal prognosis provided during a Hospice period are included in the Hospice payment and are not paid separately.

For beneficiaries enrolled in hospice, MACs should deny any Part B services furnished on or after January 1, 2002, that are submitted without either GV hospice modifier, meaning the attending physician is not employed or paid under arrangement by the beneficiary's hospice provider and professional services provided are related to the terminal prognosis, or GW modifier, meaning the service is not related to the hospice beneficiary's terminal prognosis. MACs should deny services that are submitted with the GW modifier when the service is determined to be related to the terminal prognosis. Also, MACs should deny services that are submitted with the GV modifier if it is determined that the Physician services were furnished by Hospice-employed physicians and Nurse Practitioners (NP) or by other physicians under arrangement with the Hospice.

Example 1: A beneficiary is enrolled in Hospice and goes to a physician's office for closed treatment of a metatarsal fracture, CPT code 28470. 


Resolution: If the procedure is unrelated to the terminal prognosis (Non-Hospice related), the physician's bill should contain GW modifier (Service not related to the hospice patients terminal condition). If this modifier is not appended, the procedure is related to the terminal prognosis and should not be reimbursed under the part B benefit. Thus, the claim is in error, since the services are considered included with payments under the hospice benefit. Example 2: The patient is listed as being on hospice starting August 1, 2010 through August 31,  2010. Then a provider billed CPT code 45378, Diagnostic Colonoscopy with no modifiers on August 3,2010 to Part B.


Resolution: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice and there can be no separate reimbursement unless the service was unrelated to the terminal prognosis or the attending physician was otherwise entitled to separate reimbursement, which would be reflected by GV modifier (Attending physician not employed or paid under arrangement by the patients hospice provider) or GW modifier (Service not related to the hospice patients terminal  condition). MACs should also deny services that are submitted with the modifier but for which, during medical review, the service is determined to be related to the terminal prognosis. 

Tuesday, November 8, 2011

When to use AI modifier

AI Modifier

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.



AI Modifier usage determination


• 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.



Thursday, September 23, 2010

Modifier AI Fact Sheet




Definition:

AI Modifier : Principal Physician of Record

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

Inappropriate Usage:

• Appended to procedure codes other than the initial inpatient visit or initial nursing facility care services
• Appended by physicians other than the attending or admitting physician who oversees the patient’s care
• Appended to services dated December 31, 2009 and before

Additional Information

Note: Medicare will allow services when a provider uses this modifier incorrectly 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 to his/her claim or he/she has not yet submitted the claim to Medicare.

Documentation:

The patient’s medical record indicates 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.

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