Part B Insider (Multispecialty) Coding Alert

'Don't tread on me,' say co-managing physician's toes

Recognizing which doctor is admitting a patient and which doctor is pitching in on a patient's care often is easy from the get-go. But physicians still must communicate and avoid stepping on each other's toes, say experts.

Often a specialist will admit a patient but keep a primary care physician involved in treating the patient's other conditions.

"Specialists shouldn't really be managing conditions that are not related to their specialty," says Eric Sandhusen, director of compliance with Columbia University Dept. of Surgery. Sometimes a primary care doc will call in a specialist, who in turn decides to admit the patient to the hospital. In that case, the primary care doc may keep following the patient in the hospital for conditions the specialist isn't treating, says Sandhusen.

Usually, a surgeon will have a primary care physician examine a patient and provide a pre-op clearance, notes Arlene Morrow, president of AM Associates in Tampa, FL. This often happens before admission. Also, after admission, a surgeon will notify the patient's primary care doctor of the patient's location so the primary care doc can perform rounding visits.

Sometimes, a pre-op workup after admission will reveal a problem in a patient's labs, so the surgeon calls in a non-surgical physician for a consult, Morrow notes.

Which physician bills for an initial hospital visit depends on who finds the problem that causes the admission, which physician is most familiar with the patient and which physician is best equipped to handle the problem, notes Morrow.

A lot may depend on the patient's condition, Sandhusen notes. The diagnosis may require one generalist to manage the interaction of various specialists and coordinate the patient's overall care. Or the patient may have a very specific condition that needs a single specialist's care.

Document the Reason for Second Doctor's Care

For the non-admitting physician to bill for subsequent visits, there must be a documented problem, says Sharon Tucker, president of Seminars Plus in Fountain Valley, CA. "There has to be a reason why they're [treating the patient] in addition to the physician who admitted" him or her, Tucker explains.

In particular, two doctors should avoid billing for inpatient care using the same diagnosis for the same patient, experts say. And make sure payors know both doctors aren't providing overlapping treatments for the same condition.

When you duplicate another doctor's efforts, "you're doing it for free," Sandhusen quips. Payors assume that each doctor is  competent to treat the patient, so there's no reason for more than one doctor to take a hand. Not only is the duplication medically unnecessary, but it may also raise malpractice issues if two doctors are   prescribing medications for the same condition. 

"There needs to be a clear demarcation as to where one physician's care ends and another physicians' care should appropriately begin," Sandhusen insists.

If two doctors are seeing the patient for the same diagnosis, "you just have to show the notes and show that there's a reason why you're both seeing the same patient," notes Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, NJ.

Specialty matters: Cobuzzi had one client who left a primary care group and went into business as an endocrinologist, she reports. He kept receiving denials for concurrent care until he wrote to Medicare and asked the carrier to change his specialty code from primary care to endocrinology.

Sometimes a doctor will send a patient to a specialist for a consult, and the specialist will "lay claim" to that patient's condition. Primary care docs will complain, "I wanted to get the cardiologist's opinion but I didn't want to turn my patient over to the cardiologist." Sometimes, doctors will hesitate to send patients for a consult, lest they lose that patient. Instead, physicians should concentrate on developing good communication and understanding of the concurrent care guidelines.