Primary Care Coding Alert

When family physicians (FPs) along with other specialists treat patients in the hospital, the coding can be problematic. Because two or more physicians are billing subsequent hospital care codes (99231-99233) for the same patient on the same day, Medicare and private payers may deny the claims. FPs can increase their chances of receiving reimbursement for providing concurrent care by using a primary diagnosis code that is different from that of the other specialists.

"When the payers see multiple doctors billing the same diagnosis codes for the same patient on the same day, they may not pay," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa. "There are no concurrent care CPT 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." Too often, Falbo says, FPs providing concurrent care use the reason the patient is in the hospital as their primary diagnosis code. "They should use the reason they were called in to treat the patient," she says. "They shouldn't even include the diagnosis code for why the patient is in the hospital unless it directly relates to the condition they are treating."

CMS defines concurrent care as "when services more extensive than consultative services are rendered by more than one physician during a period of time. The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient's treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services." It is usually provided when two or more separate conditions require two or more doctors for proper management of a patient. Medicare allows concurrent care to be billed for up to six different specialists treating one patient.

Medical-Surgical Concurrent Care

An FP is often called on by another specialist to treat a post- or preoperative patient for conditions unrelated to the surgery. "Although the FP is not in charge of the case, his or her particular skills are required," says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City. "It happens often when the FP is familiar with that particular patient's history. The surgeon may call the doctor in to treat a condition that he or she has been managing for a while."

For example, a patient taking Coumadin for his atrial fibrillation has to stop taking the medication to prepare for hip replacement surgery. After the surgery, the orthopedist calls in the FP to continue the Coumadin management. The FP can bill a subsequent hospital care code (e.g., 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ) with the diagnosis code for atrial fibrillation (427.31, Atrial fibrillation) and the V code for the Coumadin management (V58.83, Encounter for therapeutic drug monitoring). Denials are unlikely in this case because the orthopedist will not be billing during the postsurgery due to the global-period rules.

However, if the orthopedist is also treating the patient for a major complication due to surgery (blood clot) or a visit unrelated to the surgery (e.g., osteoarthritis of the knee), he or she will bill the subsequent hospital care codes appended with modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) and the appropriate diagnosis codes. The FP bills as above. This should not cause problems with the payers if each physician lists the diagnosis codes for which he or she is treating the patient, Falbo says.

Medical-Obstetrical Concurrent Care

Another common concurrent scenario is when the ob/gyn calls in the FP to co-manage a pregnant patient. For example, a pregnant patient with eclampsia develops pregnancy-induced hypertension. The FP is asked to treat the hypertension. Many coders would list the common hypertension code (401.1) first and the code for eclampsia (642.6x) second, but the correct diagnosis code for the FP is 642.0x (Benign essential hypertension complicating pregnancy, childbirth, and the puerperium), Falbo says. The FP should also make sure the ob/gyn reports only the diagnosis code for eclampsia. Both specialists will bill the subsequent hospital care codes.

When the FP Calls In Another Specialist

When an FP treating a patient in the hospital calls in another specialist to co-manage a case, the coding requirements are the same. For example, the FP is treating the patient for diabetes and the patient develops pneumonia and coronary artery disease (CAD). The FP asks a pulmonologist and a cardiologist to treat the patient's additional conditions. All three can bill with the subsequent hospital care codes, but each must use different diagnoses to receive appropriate reimbursement. The FP uses 250.0x (Diabetes mellitus without mention of complication), the pulmonologist uses 486 (Pneumonia, organism unspecified), and the cardiologist uses 414.0x (Coronary atherosclerosis).

Often the FP requests a consultation before determining that concurrent care is appropriate. In the scenario above, the FP may ask the pulmonologist to provide a consultation on the patient's pneumonia, instead of treating it. In that case, the FP bills the appropriate subsequent hospital visit code, and the pulmonologist uses the consultation codes (99251-99255). "It is important for coders to distinguish between consultation services, transfer of care and concurrent care," Fick says. "To bill consultations, the consulting doctor does not take over treatment of the patient, but examines him or her and makes a recommendation to the primary physician and may initiate diagnostic treatment." If the primary physician determines that the consulting doctor should take over care for the condition on which he or she consulted, the billing for the consultant then turns into concurrent care. Concurrent care can't be billed until the second day when both doctors see the patient for different reasons and they both bill the subsequent hospital care codes.

Documentation Requirements

The documentation must clearly explain the medical necessity for requiring more than one doctor to treat and manage the patient's condition. Each doctor needs to clearly document the reason he or she is treating the patient. State this in the chief complaint and history of present illness portion of the note. The medical decision-making will clearly show the different diagnosis codes for which each is treating the patient.

Note: Medicare's rules on concurrent care can be found in section 2020E of the Medicare Carriers Manual, at www.hcfa.gov/pubforms/14_car/3b2000.htm#_1_6.