EM Coding Alert

Documentation key when multiple providers administer care.

Concurrent care scenarios are among the most complex coding challenges that an E/M coder can face. But if you know how to define what is reasonable and necessary for your patient, and if you make sure that care is not duplicative, you can keep your claims clean and straightforward.

To help out, here are three great pieces of advice and some expert analysis to help you maximize reimbursement and reduce denials.

Know the Difference Between ‘Concurrent’ and ‘Duplicative’

Your first step to coding successively in these situations is understanding the basic criteria for what is and what isn’t concurrent care.

“It’s important to be able to distinguish concurrent care from duplicative care,” explains Jean Acevedo,  LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Florida.

Definition: According to CMS, “Reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient’s treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services.”

Be careful, Acevedo warns, because Medicare’s Benefit Policy Manual: Chapter 15, Section 30.E “clearly warns Medicare contractors to ‘assure that the services of one physician do not duplicate those provided by another.’”

Acevedo adds that once you understand the difference between concurrent and duplicative, you can decide which type of care you’re coding for by asking these two questions:

1. Does the patient’s condition warrant the services of more than one physician on an attending (rather than consultative) basis?
2. Are the services performed by each provider “reasonable and necessary?”

If you can answer “yes” to both questions, you’re most likely coding for concurrent care. If you answer “no” to either question, the service likely falls under the scope of duplicative care.

On concurrent care claims, “be diligent in the reporting order of the diagnoses for each claim as well,” recommends Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.

Further explanation: Let’s say one physician is treating condition A, and the other is treating condition B, but condition C is underlying. When coding for concurrent care, “condition C should not be the primary diagnosis for either service. The documentation should clearly illustrate the physician’s involvement with the patient, thus allowing for a clear illustration as to who is treating what [injury or illness],” continues Hauptman.

Focus on Diagnosis Codes Associated with Multiple Conditions

Concurrent care can occur when a patient reports to one physician for an E/M service, then that physician directs the patient to another physician for a separate issue.

As an example, think about a patient who has prostate cancer. Your urologist and an oncologist could both be involved with his care. Depending on the situation, a pain management specialist might also be brought in to treat the patient’s pain. Documentation indicates a level-three consultation service by the pain specialist, and includes a note stating that the specialist received a request for opinion from the urologist.

Urologist coding: The urologist would report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity…). Also, the coder should include a diagnosis code to represent the patient’s prostate cancer, such as C61 (Malignant neoplasm of prostate), advises Michael A. Ferragamo, MD, FACS,  clinical assistant professor of urology at the State University of New York at Stony Brook.

Pain specialist coding:  The acute pain physician would also report 99222 (for a Medicare inpatient consultation) or 99253 (Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity…) for private or commercial payers. Also, the coder should include a diagnosis code to represent the patient’s cancer pain, such as G89.3 (Neoplasm related pain [acute] [chronic]).

Both physicians are treating the patient concurrently for prostate cancer, but with a different symptom focus.

Key point: Although our prostate cancer example highlights concurrent care for two separately diagnosable conditions, different ICD-10 codes for each concurrent care provider are not always necessary. “Two physicians may indeed treat a patient for the same condition and bill the same ICD-10 code for their E/M service,” says Acevedo.

Stellar Notes Can Boost Your Claims Success

You know that solid documentation is never a bad thing — that’s Coding 101-type information. However, it is even more important when you’re coding for concurrent care, especially when both providers are submitting the same ICD-10 code.

“I always advocate that two physicians treating a patient for the same condition and submitting claims with the same ICD-10 codes should fully explain the circumstances in the clinical record,” advises Acevedo. Remember, however, that some payers may deny concurrent care when the diagnosis is the same for each provider.

Benefit: If a payer questions whether the care is concurrent or duplicative, “a complete progress note is the best defense,” she says.