General Surgery Coding Alert

Emphasize Surgeons Expertise To Increase Concurrent Care Pay

Published on Sun Jun 01, 2003

When a surgeon works concurrently with other physicians to treat a patient, you'll stand a better chance of receiving full pay for the surgeon's services if the claim establishes that the care he or she provided was necessary because of special training or expertise in his or her specialty.

Trauma surgeons in particular will likely encounter concurrent care situations. If, for instance, a trauma surgeon is providing overall coordination of care for a patient with a closed head injury, the surgeon will likely work with a neurosurgeon or neurologist to provide services for the patient, coding experts say. Likewise, a trauma surgeon may work concurrently with an orthopedic surgeon to provide care for a trauma patient with bone or joint injuries.

To support medical necessity for the surgeon's particular services and to further distinguish his care from that of the other physicians, you should ensure that the diagnosis codes are as precise as possible and linked directly to the services the surgeon performed. Remember that the more precise the diagnosis code, the more likely you'll be to show the medical necessity of the care delivered.

When the trauma surgeon continues to see a patient whose serious injuries are being treated by other physicians and no other diagnoses are available, the trauma surgeon should code as many injuries as possible to emphasize the coordinating aspects of his participation.

Understand 'Concurrent Care' Definitions

Knowing what payers mean by "concurrent care" is crucial to securing reimbursement. The Medicare Carriers Manual, Section 2020, defines concurrent care as occurring when more than one provider at a time provides services more extensive than a consultation.

Thus, when more than one provider performs follow-up hospital care (E/M services) on the same day to the same Medicare patient, they would technically meet this definition of concurrent care, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. and compliance manager for several cardiology groups around the country.

Collins stresses that Medicare requires the following criteria for concurrent care services:

both providers must be actively participating in treatment

the patient's condition must warrant the services of both providers

the services must meet Medicare's definition of "reasonable and necessary." According to Medicare, reasonable and necessary services are "considered under accepted standards of medical practice to be a specific and effective treatment of the patient's condition."

If two physicians treating the same patient meet all three conditions, carriers will typically pay both claims if each physician reports a unique diagnosis on the claim, Collins says. "Reporting a unique diagnosis code that no other provider is using is the cleanest and most efficient way to obtain reimbursement for concurrent care."

Collins stresses, however, that this is easier said than done because most physicians do not share billing information with other members of the healthcare team. And many carriers follow the policy of paying the first claim submitted with a diagnosis code and denying subsequent ones. This puts those practices that submit claims on a daily basis at a competitive advantage over those that wait until the patient is discharged, Collins says.

Copycat Codes Could Mean No Payment

As a good rule of thumb, you should code to the ultimate level of specificity and certainty, Collins stresses. If your provider is consulted for a sign or symptom and he or she makes a definitive diagnosis when taking over a portion of the patient's care, report the definitive diagnosis rather than the sign or symptom. By relying on this diagnosis, you will most likely avoid reporting the same diagnosis code as other providers because they are most likely to report the sign or symptom or another unrelated diagnosis, he says.

For example, if a patient has multiple injuries and the trauma surgeon performs a splenectomy, an orthopedic surgeon may perform a fracture reduction prior to the procedure. The trauma surgeon will report the spleen diagnosis, such as ruptured spleen (865.04), to support medical necessity for the splenectomy and link it to the appropriate surgery code.

Keeping the descriptions of specific services separate is vital, emphasizes Sandy Fuller, CPC, a coding and reimbursement specialist in Abilene, Texas.

For example, when a vascular surgeon and a radiologist both provide services, such as during an endovascular repair of an abdominal aortic aneurysm (AAA), the surgeon and the radiologist would report the appropriate diagnosis code, such as 441.4 (Abdominal aneurysm without mention of rupture), and the surgeon would link this to the appropriate AAArepair code for prosthesis insertion (34800-34804).

Although CPT specifies that the radiological supervision and interpretation (S&I) code for angiograms performed with this procedure (75952, Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) is separately reportable, the radiologist, rather than the surgeon, would bill 75952 if the radiologist performed the S&I services.

(See "Endovascular AAA Repairs, Part 2: Complete Your Reimbursement by Claiming All Separately Reportable Procedures" in the May 2003 General Surgery Coding Alert for more on coding AAA procedures.)

Improve Expert Care Documentation

If you find denials for concurrent care becoming a problem for your surgery practice, try the following tactics:

To illustrate that the patient required your surgeon's expertise, submit a paper claim (or appeal if necessary) with supporting documentation.

Submit a copy of the provider's note and notification that he or she fits into a different specialty or subspecialty than other providers caring for the patient (such as trauma surgery, vascular surgery or cardiothoracic surgery). You can also indicate your provider's subspecialty on the appropriate CMS form (box 19 on CMS-1500), which will help reduce denials and keep your provider in the running in the claims-submission race, Collins says.