Corporate

November 15, 2013

“Principal Physician of Record”: HCPCS Modifier AI

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 providers who may be furnishing patient 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.
  • 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 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 may not be paid.

If your claim has been submitted using the appropriate E/M code but 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 physician's claim did not include HCPCS modifier AI. You may wish to contact the referring physician's office to inquire further.

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.

Claim reopening tips and instructions: call 1.866.276.9558 or complete and submit the Reopenings Adjustment Form.

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