Primary Care Coding Alert

$$$ can fly out the door if ICD-9 overlap afflicts claim.

Getting the most accurate ICD-9 codes possible for your FPs services will go a long way toward preventing denials when coding for concurrent care. Follow this case study and learn how to ensure that everyone is getting paid for their services.

Remember Consult Exception

When your FP provides concurrent care with other specialists on a patient, you must be sure that each physician is treating a separate patient problem; otherwise, only one physician will get paid, even if each physicians service is medically necessary.

Confusion surrounding concurrent care can start when the FP is treating a hospital inpatient and calls in physicians for consultation. Consider this example from Jill M. Young, CPC, CEDC, CPC-IM, with Young Medical Consulting LLC in East Lansing, Mich:

The FP is treating an established patient with controlled type II diabetes with ketoacidosis as a hospital inpatient. On Tuesday morning, the FP checks on the patient during his rounds, and the patient complains of shortness of breath (SOB). Suspecting either pneumonia or heart failure, the FP calls in a pulmonologist and a cardiologist for consultation.

All three physicians can code for their services with a primary diagnosis of shortness of breath (786.05) because they were all treating that condition. The FP would choose a subsequent hospital care code (99231-99233), and the other specialists would each choose an inpatient consult code (99251-99255). All three claims are valid because two of the [services] were consults. The one diagnosis per doctor, per day exception is the consult, Young says.

The problems can arise the next day, when more than one physician tries to bill for hospital care.

Same Dx Creates Claim Race

The above example becomes a concurrent care scenario Wednesday morning, when tests confirm that the patient has viral pneumonia. The cardiologist is no longer needed, but the FP decides to call the pulmonologist in to take over care for the patients pneumonia. The FP, however, continues to see the patient for management of his diabetes. Notes indicate that the FP provided level-two care.

It is vital that each physician provide diagnosis codes to explain the exact patient problem he is treating. If the FP does not indicate that he is treating the patients diabetes, someone is not going to get paid, Young says.

Problem 1: Filing a 99232 (Subsequent hospital care,per day, for the evaluation and management of a patient,which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity ...) claim with the SOB diagnosis is misleading because that is not what the FP is treating.

Problem 2: If the FP follows suit with the pulmonologist and files with 480.9 (Viral pneumonia, unspecified),then the race is on: whichever claim gets to the insurer will be paid, the other will not, Young predicts. Even if the insurer accepts the claim, however, it is not good practice to code for pneumonia care when your FP does not provide it. The pulmonologist wont like it, and it could bring your claims added insurer attention in the future.

If you lose the race on the above claim, it would cost the practice about $67 (1.85 transitioned relative value units [RVUs] multiplied by Medicare 2009 conversion rate of 36.0666). And getting an appeal through on concurrent care is difficult. Unless, Young says, you can convince the pulmonologists office to return their pay for the service.

Solution: You can code the patients condition completely, but be sure that you order your ICD-9 codes properly, reminds Catherine Brink, CMM, CPC,CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

So the pulmonologist should report his hospital care code with 480.9 appended as a primary diagnosis and 250.10 (Diabetes with ketoacidosis; type II or unspecified type, not stated as uncontrolled) as a secondary diagnosis. The FP should report 99232 with 250.10 as primary and 480.9 as secondary.

This will ensure that both practices get paid -- and that youve painted a complete picture of the patients condition.

Coordinate With Other Offices to Avoid Overlap

When coding for concurrent care, its the [diagnosis] overlap stuff that causes the most problems, explains Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. Combat this problem with solid encounter notes indicating each physicians role in patient care, he recommends.

Example: For the above scenario, a good encounter note might read: provided care on inpatient basis, for management of patients diabetes/ketoacidosis. Pulmonologist also provided care for patient, to manage and treat viral pneumonia.

If you are worried about submitting a claim with the same diagnosis as another physician, call to be sure each practice is reporting the proper diagnosis codes.