Suppose a patient gets admitted to a hospital. There are two physicians who round on the patient every day. One is a junior physician who admitted the patient, and the other is a senior cardiologist who is basically called in to manage the patient’s heart condition.
Both physicians perform their initial evaluation, and both want to bill for it. However, if both physicians use the same code for the same patient on the same date, payers might flag them as duplicate claims, leading to denials. So, what’s the solution to this problem?
The answer is the AI modifier. In this guide, we will explain what this modifier is, when it is used, and how you can use it correctly in your claims. So, let’s start.
AI Modifier – Description
The AI modifier is defined as:
“Principal Physician of Record.”
So, what exactly does this mean? Let’s clue you in.
AI is an informational modifier and is appended to an initial hospital care code or an initial nursing facility care code. It is used to identify the physician (usually the admitting or attending physician) who oversees a patient’s overall care during an inpatient stay.
But the usage of this code isn’t simple. To help you understand when this modifier is used, let’s look at the background of this modifier.
In January 2010, CMS stopped payment for the consultation code sets (99241 to 99245 and 99251 to 99255). Before this change, only the admitting physician billed an initial hospital care code, while every other physician evaluating the patient had to use a consultation code.
However, this change created a paradox. Now that both the admitting and subsequent care physicians were using and billing the same codes for the same patient on the same date, the claims were at risk of being flagged as duplicates.
So, to solve this issue, CMS introduced the AI modifier. Hence, the physician who oversees the patient’s care, commonly the hospitalist, admitting physician, or attending internist, appends modifier AI to identify themselves as the principal physician of record. Every other physician performing an initial evaluation bills the same code range without the modifier.
Scenarios Where the AI Modifier is Applicable
To clear the picture, here are a couple of real-world scenarios in which the AI modifier can be used:
Scenario 1
Suppose a patient has pneumonia and shortness of breath. He is admitted to the hospital. The attending physician who admitted the patient performs the initial hospital care visit, documenting a comprehensive history, examination, and plan of care, then bills CPT code 99223.
Later that day, a specialized pulmonologist also visits and evaluates the patient because of the oxygen issues. The pulmonologist also bills the visit with a code from the 99221-99223 range. However, since the attending physician is the one directing the overall care, he also reports the initial hospital care code but with the AI modifier appended to it.
Scenario 2
Consider another scenario. A patient with worsening mobility and cognitive decline is admitted to a nursing facility. The attending physician performs a comprehensive initial assessment, develops the plan of care, and bills CPT code 99305 to indicate that the encounter involved moderate-complexity medical decision-making.
Later that same week, a nurse practitioner from an unrelated specialty group evaluates the patient for a separate, medically necessary concern.
In this scenario, the attending physician appends the AI modifier to the initial nursing facility care code, since he is the principal physician of record, while the nurse practitioner will report the appropriate initial nursing facility care code without the modifier.
AI Modifier – Billing Guidelines
Apart from what we have discussed, there are some additional guidelines that you need to consider while using modifier AI in your claims. Here’s what you need to know:
Only One Principal Physician of Record
For any single admission, only one physician can be the principal physician of record. If two physicians of different specialties append AI to their claims, in most cases, the payer will process only one claim and reject the other.
Valid Code Ranges Only
The AI modifier is only valid when appended to initial hospital care codes or initial nursing facility care codes. Appending it to subsequent visit codes, office and outpatient codes, or emergency department codes is wrong.
You can use AI with the following codes:
- 99221 – 99223
- 99304 – 99306
Conclusion
That’s it; we have reached the end of our guide. In this blog, we discussed what the AI modifier is, when you can use it, and some important guidelines that will help you use this modifier correctly in your claims. Before concluding, let’s revisit the important points that we discussed:
- AI identifies the principal physician of record on initial hospital care or initial nursing facility care.
- Only one physician per admission should use this modifier.
- The modifier does not change the reimbursement amount and is only used for informational purposes.
- It is only valid with the 99221 to 99223 and 99304 to 99306 code ranges.
Getting a modifier like AI wrong is a small mistake with an outsized effect on your cash flow, and it is exactly the kind of detail that outsourced medical billing services are built to catch. If you are having problems with medical billing and coding, try consulting our expert team at MediBillMD.
