Internal Medicine Coding Alert

Internists billing inpatient hospital visits as concurrent care need to emphasize the condition he or she is treating, which may not be the same reason why the patient is in the hospital. They should also consider whether the evaluation and management (E/M) service qualifies as an inpatient consultation, even if the internist eventually ends up providing concurrent care to the patient on an attending basis. Following these guidelines will bring optimum reimbursement for the provided services.

Concurrent care occurs when two or more physicians are treating the same patient on the same day, according to Emily H. Hill, PA-C, president of Hill & Associates, a medical practice and consulting firm in Wilmington, N.C., and a member of American Medical Associations (AMA) Correct Coding Policy Committee. The patients condition must warrant the services of more than one physician on an attending basis, which means that the patient will probably have different diagnoses that require treatment by physicians of different specialties.

As an example of concurrent care, Hill cites a situation in which an internist admits a patient to the hospital for pneumonia. The patient also is diabetic, and that condition has become worse as a result of the pneumonia. A pulmonologist is asked to treat the patients pneumonia, while the internist continues to treat the patients diabetes. Because the internist did the hospital admission, he or she would bill one of the initial hospital care codes (99221-99223). Both physicians would be able to report a subsequent hospital care code (99231-99233) to cover the continuing evaluation and management of the patient. No modifier is necessary to report the concurrent care visits.

Even though two physicians are seeing the patient, concurrent care may not be occurring, Hill says. Changing the previous example slightly, Hill cites a situation in which a cardiac surgeon admits a patient to the hospital for heart surgery. The patient also is diabetic, so the surgeon asks an internist to monitor that aspect of the patients condition after the surgery is completed. Because the surgeon is in the global period of the surgical procedure, he or she cannot report additional evaluation and management services, and there is no concurrent care. The internist still would be able to report the appropriate level of subsequent hospital care code.

Primary Diagnosis Is Condition Being Treated

The key to being consistently reimbursed for concurrent care, according to Hill, is to stress the different conditions being treated. Internists need to report on the claim the condition that they were personally treating, she explains. In the first example where the internist and the pulmonologist were providing concurrent care, she suggests that the internist list diabetes as the primary diagnosis code and pneumonia as the secondary one. The pulmonologist should list pneumonia as the primary diagnosis on his or her claim.

Internists must also be able to document that their services were medically necessary to the patients treatment. Stopping by the patients room for a social visit or to see how he or she is doing doesnt constitute concurrent care, says Hill. The same elements of history, examination and medical decision-making that are a part of all E/M services must be part of a concurrent care visit.

In addition, the patients medical record should detail the specific services provided by the internist. The medical record should reflect the internists active involvement with the patient, Hill explains. There should be enough documentation in it to determine the role each physician played.

Concurrent Care Can Be Billed in the ICU

When a patient in the intensive care unit (ICU) is seen by two physicians, theres often some question over whether concurrent services can be reported. Thats because internists make the mistake of thinking that if someone is in the ICU then he or she must be getting critical care, and only one physician can bill for critical care, notes Hill.

The mere fact of being in the ICU does not mean that the patient is receiving critical care, says Brett Baker, third-party relations specialist with the American Society of Internal Medicine. Medicare allows only one physician to bill for a given hour of critical care, although a second physician can report a subsequent hospital care code if he or she is also providing care to a critically ill patient. But both Medicare and CPT acknowledge that not all patients in the ICU are critically ill.

If a patient is not critically ill, says Baker, there are no restrictions on concurrent care in the ICU.

Inpatient Consult or Concurrent Care?

Internists also need to distinguish between concurrent care and a consultation, says Baker, who adds that inpatient consultations (99251-99255) have higher relative value units than the corresponding subsequent hospital care codes. Medicare and CPT have the same basic criteria for what constitutes a consultation. A request for an evaluation from the patients physician must be recorded in the patients medical record. After the evaluation, the consulting physician must provide a written report of his or her findings to the requesting physician. A consulting physician may initiate diagnostic and/or therapeutic services at the time of the evaluation or during a subsequent visit, and the service will be considered a consultation as no transfer of care occurs at the time of the request for an evaluation.

Baker believes that many internists get confused about whether a transfer of care has occurred because they are often asked after the consultation to manage a portion of the patients care. The internist has to ask whats his or her role in seeing the patient, he says. If the specialist wants to hear an opinion from the internist, then its a consultation.

Primary Care Physicians Also Do Consults

Even if the internist happens to be the patients primary care physician, he or she could be asked by a specialist to perform a consultation. A cardiac surgeon could ask an internist to do a consultation for preoperative clearance on a patient, who considers the internist to be his or her primary care physician, Baker explains. If the cardiac surgeon later asks the internist to come back and actively manage a portion of the patients care, then the consultation has evolved into concurrent care. The preoperative clearance would still be considered a consultation, and the other visits would be reported as a subsequent hospital care code.

The Medicare Carriers Manual sections 15506 (E) and (F) specifically address the question of inpatient consultations and concurrent care and make the following points:

Consultations for preoperative clearance for a new or established patient performed by any physician at the request of a surgeon will be paid as long as the requirements for billing the consultation codes are met.

A physician who has performed a preoperative consultation and assumes responsibility for the management of a portion or all of the patients condition(s) during the postoperative period should use the appropriate subsequent hospital care codes (not follow-up consultation codes) to bill for the concurrent care he or she is providing.

A physician (primary care or specialist) who performs a postoperative evaluation of a new or established patient at the request of a surgeon may bill the appropriate consultation code as long as the criteria for a consultation are met and that same physician has not already performed a preoperative consultation.

If the surgeon asks a physician who did not see the patient for a preoperative consultation to manage the patients condition during the postoperative period, the physician may not bill a consultation because the surgeon is not asking for the physicians advice in treating the patient. The physicians services would constitute concurrent care and should be billed using the appropriate level visit codes.