Primary Care Coding Alert

Family physicians (FPs) reporting services concurrently with other specialists should follow two rules of thumb to ensure appropriate payment:

1) The diagnosis or diagnoses must support the medical necessity of involving two specialists in the patients care, and

2) It must be clear why both doctors were needed and that the family physician alone was not qualified to provide care for all presenting conditions.

According to Charlotte Price, RHIA, CCS-P, documentation and coding specialist for Clinical Financial Services, supporting 250 physicians at the Brody School of Medicine in Greenville, N.C., FPs treat a wide variety of injuries and illnesses that may require additional services provided by other specialists. This presents situations where the FP may submit a claim on the same date of service as another physician, she explains. This will attract the attention of reviewers, who will want clear indication about why there was a need for concurrent care.

Concurrent care is allowable in cases where services more extensive than consultations are provided, and where both physicians play an active role in the patients ongoing care.

Concurrent care occurs with both in- and outpatients, although it is more common with inpatients, explains Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians based in Kansas City, Mo. I see this most often when two doctors report subsequent hospital care codes (99231-99233) concurrently.

For example, he says, the FP may have admitted a patient suffering from hypertension (e.g., 401.0, essential hypertension, malignant) and diabetes (e.g., 250.43, diabetes with renal manifestations, type I, uncontrolled). However, the patient may also have congestive heart failure (428.0) of such severity that the condition justifies both the FP and a cardiologist caring for the patient.

This combination of diagnosis codes makes it very clear why two specialists are needed, he points out. And because the conditions demand specialized care, there would be little question that the services each provides are reasonable and necessary.

Price says that in her multispecialty center concurrent care is sometimes justifiable with outpatients. This may occur when the FP is treating the patient for an underlying condition, but then discovers a more acute problem, she says. Or complications or emerging problems may require that a subspecialist also become involved.

For instance, an FP may be having limited success with pneumonia treatment because the disease is resistant to typical therapies. So, the FP may ask one of our pulmonologists to see the patient as well. Another example is a patient who has an infection but suddenly develops a severe rash as well. In this case, the FP may ask the practices dermatologist to examine and treat that condition, Price says.

Moore points out that Medicare guidelines for concurrent care are explicitly spelled out in section 2020.E of the Medicare Carriers Manual. It notes that it is usual for concurrent care to be performed by physicians in different specialties (e.g., a family physician and a surgeon) or in different subspecialties of the same specialty (e.g., an allergist and a cardiologist both subspecialties of internal medicine). Less common is concurrent care performed by physicians in the same specialty or subspecialty (e.g., two family physicians or two pulmonologists). An exception is when one of the specialists has limited his or her practice to an unusual aspect of that specialty (e.g., tropical medicine).

Payment will not be made for concurrent care, Moore adds, if the services exceed the normal frequency or duration parameters, unless unusual circumstances arise. Nor will carriers reimburse concurrent care services if the services of one physician duplicate another, he points out. An example is if the FP visits a postsurgical patient as a courtesy but provides no care that the surgeon is not able to provide.

He adds that if carriers determine that services of one physician are not warranted by the patients diagnosis or that the physician does not demonstrate unique qualifications to treat the condition, Medicare will pay only for the other physicians services.