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May 1, 2013

Consulting Physicians, "Principal Physicians of Record," and HCPCS Modifier AI

Effective for dates of service on or after January 1, 2010, Medicare no longer recognizes CPT codes for "consultations" (CPT codes 99241-99245 and 99251-99255). This change has important implications for both consulting physicians and "principal physicians of record."

All Physicians:

  • Both physicians making referrals and physicians accepting referrals should document these requests. Documenting these requests is in keeping with conventional medical practice and ensures coordination of care.

What This Means for "Principal Physicians of Record":

  • It is imperative that the "principal physician of record" submit HCPCS modifier AI with claims for initial hospital and nursing home visits.  This modifier identifies the physician as the principal physician who oversees the patient's care, separately from all other physicians who may be furnishing specialty care.
  • Although HCPCS modifier AI may be submitted by the principal physician with all claims for E/M services, it is particularly important that this modifier be submitted with initial hospital and nursing home visits.
  • If the principal physician's claim for initial hospital or nursing home visits does not include HCPCS modifier AI, claims for other E/M services rendered on the same date by consulting physicians may not be paid.
  • To request that CGS add HCPCS modifier AI to a claim that has already been submitted and processed, you may request a telephone or written claim reopening.

What This Means for Consulting Physicians:

  • Consulting physicians should:
    • Continue to "follow appropriate medical documentation standards" for documenting and selecting the level of CPT code that reflects the Evaluation & Management (E/M) service provided.
    • Provide the results of an evaluation to the requesting physician.
  • Submit the appropriate E/M code that reflects the level of service provided.
  • If your claim for consultative services (submitted using the appropriate E/M code) is denied with remark code M86 (service denied because payment already made for same/similar procedure within set time frame), it is likely that the principal (usually the referring) physician's claim did not include HCPCS modifier AI. You may wish to contact the referring physician's office to inquire further.


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