Medicare Compliance & Reimbursement

Medical necessity and time spent will dictate payment.

If a patient is brought in to the emergency department with more than one medical condition, two or more physicians might need to attend. However, you'll need to keep an eye out for circumstances that might land you in claim scrubber land.

When one provider performs cognitive E/M services and another performs a procedure, payment issues are relatively rare. On the other hand, when two physicians provide E/M services during the same ED visit, watch out for claim scrubber errors and payer denials, says
Betty Ann Price, BSN, RN President and CEO of PRCS, Inc. in Palmetto, Florida. Historically, one provider would utilize ED E/M codes (99281-99285) and others would report a consultation code (99241-99245). Reimbursement may be dependent upon a combination of factors under the umbrella of medical necessity.
 
Medicare describes concurrent care as when more than one physician renders services more extensive than consultative services during a period of time. The waters were muddied, however, when Medicare eliminated consultation codes in 2010, says Price. In order to determine whether concurrent physicians' services are reasonable and necessary, the carrier must decide the following:
 
1. Whether the patient's condition warrants the services of more than one physician on an attending (rather than consultative) basis, and
 
2. Whether the individual services provided by each physician are reasonable and necessary.
 
In resolving the first question, the carrier should consider the specialties of the physicians as well as the patient's diagnosis, because concurrent care is typically initiated because of the existence of more than one medical condition requiring diverse specialized medical or surgical services. The specialties of the physicians are an indication of the necessity for concurrent services, but the patient's condition and the inherent reasonableness and necessity of the services, as determined by the carrier's medical staff in accordance with locality norms, must also be considered, says Price. (Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30; Page 13 of 280).

Don't Forget Modifier 27 For Facility

Coders should be aware of diagnosis code sequencing when other specialties are billing for concurrent services. For example, when Toxicology is consulted to evaluate a patient presenting with altered mental status, respiratory failure and poly-substance overdose, keep in mind that Toxicology ICD-9 codes will focus on the overdose. While different diagnosis codes are not required for multiple E/M levels occurring on the same date of service, different primary diagnoses may encourage payers to recognize medically necessary services, warns Price.

CPT
® modifiers offer little to support separately identifiable services by two physicians providing concurrent care. The 25 modifier is used to indicate separately identifiable services by the same physician on the same date of service. In other words, the 25 modifier is not appropriate to distinguish between two E/M services performed by different providers, says Price. The 27 modifier is currently approved for hospital outpatient (facility) use only. Modifier 27 does not describe professional services, she adds.
Only One Provider May Report A Period Of Time Of Critical Care

Medically necessary critical care services provided on the same calendar date to the same patient by physicians representing different medical specialties that are not duplicative services are payable.

The medical specialists may be from the same group practice or from different group practices. Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient, says Price.

Check Out This Clinical Example of Correct Time Billing

A patient arrives in the emergency department in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, subsequently providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (99291) and not also emergency department services. The cardiologist may report the 35 minutes of critical care services provided in the ED. Additional critical care services by the cardiologist in the CCU may be reported on the same calendar date using 99292 or another appropriate E/M code depending on the clock time involved.