Pulmonology Coding Alert

How would you bill two physicians who see the same patient on a given day?

Coding concurrent care for your pulmonologist's services? Make sure you pick out the most accurate ICD-9 codes possible if you want to get the most out of your claim.

Definition: Concurrent care involves two or more physicians from different specialties who work handin- hand to service the same patient. Physicians doing concurrent care must be involved for a definite purpose, meaning their services must meet requirements of medical necessity. Subsequently in order to get paid, your documentation should be able to justify the related services provided by these physicians.

Make use of two basic guidelines with this concurrent care scenario:

Scenario: The pulmonologist treats a hospital inpatient with viral pneumonia. During the doctor's rounds, the pulmonologist checks on the patient who complains of coughing up pink mucus. Suspecting possible heart failure, the pulmonologist calls in a cardiologist for consultation. The next day, the tests that the cardiologist orders confirm the patient's heart failure. Upon the pulmonologist's request, the cardiologist takes over care for the patient's heart failure. At the same time, the pulmonologist continues to see the patient for management of his pneumonia. How should you report this next day's services?

Overlapping Diagnosis Presents A Red Flag

Each physician should provide diagnosis codes that support the medical necessity of engaging two physicians in the patient's care. In the given example, the pulmonologist should indicate that he is treating the patient's pneumonia, while the cardiologist should explain that he is treating the heart failure. Here's how you'd report it:

• For the pulmonologist, you should report a hospital care code (99231-99233) with 480.9 (Viral pneumonia unspecified) appended as a primary diagnosis, and 428.0 (Congestive heart failure, unspecified) as a secondary diagnosis.
• For the cardiologist, you should report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) with 428.0 as primary and 480.9 as secondary diagnosis.

Catch: If both physicians billed for the same condition(s), one of them might not get paid for the claim. Nevertheless,you can code the patient's condition completely, says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J., but be sure that you place your ICD-9 codes in proper order, along with the documentation addressing each condition.

Describe Each Physician's Unique Service

Sometimes, one of the physicians might assume total care for all presenting conditions. To avoid any misunderstanding, encounter notes should indicate each physician's role in patient care. For instance, the pulmonologist in our example should document details of the assessment and plan as it relates to the pneumonia while the cardiologist would focus on the note details surrounding heart failure. Commenting on issues that the physician is not managing can be done if the physician describes how the condition unrelated to his/her care affects and prescribed therapies or management options. Sure, two or more providers can get involved in a patient care, but claims submitted by multiple providers will likely be denied if providers use the same primary diagnosis code on the same date of service. You can get around problems with billing concurrent care by observing the following criteria:

1. Physicians provide care that is medically necessary based on the patient's clinical presentation.

2. Each provider manages a separate problem or condition.

3. Each provider bills the primary diagnosis code that match the problem or condition.