Neurology & Pain Management Coding Alert

Insurers typically specify strict guidelines for payment of more than one service for the same patient on the same day, especially if two or more physicians work together to provide care. Nevertheless, physicians providing medically necessary "concurrent care" should expect full reimbursement for their services and can get it if they document thoroughly and assign ICD-9 codes appropriately.

The Medicare Carriers Manual (MCM), section 2020 E, states, "Concurrent care exists where services more extensive than consultative services are rendered by more than one physician during a period of time." In other words, two or more physicians are actively involved in the patient's care, beyond the level of providing a written report of the patient's condition to a "requesting" physician. In addition, no transfer of care from one physician to another occurs. Rather, two or more physicians share responsibility for the patient, co-managing a single condition or (more commonly) tending to distinct, coexisting medical problems.

Providers rendering concurrent care may include physicians, physician assistants, nurse practitioners, clinical nurse specialists, psychologists and others. The services may be inpatient or outpatient, but generally occur in an inpatient (facility) setting.

Note: Medicare allows as many as six different specialists to report concurrent care for a single patient. Private payers follow similar guidelines.

Demonstrate Necessity

Insurers will not reimburse for unnecessary or redundant services. To gain payment for concurrent care, therefore, you must provide solid documentation to demonstrate medical necessity. According to the MCM, "To determine whether concurrent physicians' services are reasonable and necessary, the carrier must decide (l) 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." The MCM goes on to note, "Correct coverage determinations can be made on a concurrent care case only where the claim is sufficiently documented for the carrier to determine the role each physician played in the patient's care."

To reach a payment decision, the payer will first consider the specialty of each physician to determine if the patient's diagnosis(es) requires (in Medicare's words) "diverse specialized medical or surgical services."

"For example, a primary-care physician [PCP] requests a consult for a patient with a suspected diagnosis of carpal tunnel [354.0]," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J. If the neurologist confirms the diagnosis, he or she will issue a report to the requesting physician, who will either initiate treatment or transfer care to the neurologist. "But a diagnosis of carpal tunnel alone would usually not justify both physicians' continuing involvement," she explains. A more complex diagnosis, such as multiple sclerosis (340) or Parkinson's (332.0), or two or more coexisting conditions, would more likely support the necessity of concurrent care.

By this same reasoning, payers likely will not view concurrent care as reasonable and necessary if provided by physicians of the same specialty or by physicians with a similar knowledge base. According to the MCM, "The need for [concurrent care] by physicians in the same specialty or subspecialty (e.g., two internists or two cardiologists) would occur infrequently since in most cases both physicians would possess the skills and knowledge necessary to treat the patient." The only exception to this rule is if one of the treating physicians "has further limited his/her practice to some unusual aspect of that specialty" and documentation can unequivocally support medical necessity for the unique contribution of that physician.

Individual payers have provided additional guidelines to ease concurrent care reporting. For example, Cahaba GBA, the part B carrier for Alabama, Georgia and Mississippi, as well as other Medicare carriers, specifies that when three or more physicians of any specialty, or two physicians of the same specialty, submit claims for concurrent care, each physician's claim should note his or her specialty (the physician specialty code for neurology is 13) and the condition he or she treated. In addition, the payers recommend that the claim contain a copy of the physician's patient evaluation, the names of all physicians providing concurrent care, and (for inpatients) documentation indicating that the billing physician is not the attending physician.

Finally, payers will apply the usual medical-necessity and frequency limitations on each physician's services. "Just because the patient qualifies for concurrent care," Jandroep warns, "you don't have permission to bill whatever you want. All the usual rules apply."

Physicians providing concurrent care must be careful when assigning ICD-9 codes. Payers often want to see distinct diagnoses from each of the physicians. "If both physicians report the same diagnosis, even as a secondary diagnosis, the payer is more likely to reject the claim, especially if the physicians are of similar specialties," says Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa.

"There are no concurrent care modifiers or CPT codes you must use the standard E/M and procedure codes so the only way to tell the payer that you're providing services separate from another specialist is to use a different primary diagnosis code," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa. Too often, Falbo says, the physician providing concurrent care uses the reason the patient is in the hospital as the primary diagnosis. "They should use the reason they were called in to treat the patient," she says. "They shouldn't even include the diagnosis describing why the patient is in the hospital unless it directly relates to the condition they are treating."

Therefore, a neurologist providing concurrent care to a diabetic patient (as an inpatient or outpatient) should assign an ICD-9 code for the specific disorder he or she is treating, for instance, diabetic neuropathy (357.2, Poly-neuropathy in diabetes; in this instance you would also list the underlying disease, 250.6x, Diabetes with neurological manifestations). A simple diagnosis of diabetes (250.xx) without additional information will leave the payer wondering why the neurologist's services are necessary.

Returning to an earlier example: The PCP turns a patient over to a neurologist for treatment of carpal tunnel but continues to treat the patient for an unrelated problem, e.g., esophageal reflux, 530.81. Both physicians can see the patient on the same day and even report the same CPT code (e.g., 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) as long as ICD-9 coding shows that the physicians treated the patient for distinct problems (neurologist, 354.0; PCP, 530.81).

Concurrent care's unique documentation challenges may require that you coordinate your coding and billing with the other caregivers. As noted, diagnosis codes should not overlap whenever possible, and two or more physicians must not report identical services (e.g., routine hospital visits for the same condition) or their claims will face denial. In addition, the MCM warns, "Physicians should remember that Medicare is not in a position to determine which of several physicians is 'primary' or 'attending.' Because of this, when after review of documentation, concurrent care cannot be found to be medically necessary, national Medicare policy is to pay the physician whose claim is first submitted, and deny the subsequent ones."

Note that concurrent care coverage does not apply to emergency room services or critical care services. Although Medicare allows only one physician to report for a given hour of critical care, a second physician can report outpatient E/M services if he or she also provides care to a critically ill or injured patient in the emergency room. More than one physician can provide critical care services to a patient on the same day if the physicians meet the requirement for critical care services they just cannot provide critical care during the same hour.