Cardiology Coding Alert

If two doctors treating the same patient meet all three conditions, carriers will typically pay both claims if each physician reports a unique diagnosis on the claim, Collins says. "This is the cleanest and most efficient way to obtain reimbursement for concurrent care," he observes. That goes for Medicare and private carriers. (See page 76 for more information on concurrent care claim strategies for Medicare and private payers.)

As a good rule of thumb, you should code to the ultimate level of specificity and certainty, Collins says. "If your provider is consulted for a sign or symptom and he or she makes a definitive diagnosis when taking over a portion of the patient's care, report the definitive diagnosis rather than the sign or symptom. By relying on the diagnosis, you will most likely avoid reporting the same diagnosis code as other providers," he says.

For example, if a cardiologist is following a patient who is in the hospital after bypass surgery or valve replacement surgery, the surgeon will use the cardiac diagnosis (e.g., aortic aneurysm, 441.9), says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas.

"In our practice, after the cardiologist does the heart catheterization, he or she withdraws from the case and lets the surgeon take over," Fuller says. The cardiologist provides additional services to the patient only if the surgeon requests that he or she treat a specific problem, such as atrial fibrillation (427.31) or hypertension (402.x). If the cardiologist only provides specific services at the request of the surgeon, this eliminates the concurrent diagnosis situation, she adds.

Indeed, "both physicians reporting the same diagnosis, even as a secondary diagnosis, can lead to a claim rejection," especially when the physicians are in similar specialties, confirms Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa.

Keeping the descriptions of specific services separate is vital, Fuller emphasizes. For example, when a cardiologist and an electrophysiologist treat the same patient, she uses rhythm diagnoses such as atrial fibrillation or syncope (780.2) for the electrophysiologist, and regular cardiac diagnostic codes for the cardiologist, such as those indicating coronary artery disease or hypertension.

Showing medical necessity is a must, experts stress. Stopping by a patient's room to check on progress or for a social visit does not constitute concurrent care. The same components of all E/M visits - history, examination and medical decision-making or counseling/coordination of care time - must be part of the concurrent care visit.

In addition, the patient's medical record should detail the specific services the cardiologist provided. The record should also reflect the physician's active involvement with the patient, and there should be sufficient documentation to determine the role each physician played.

When two physicians see a patient in the intensive care unit (ICU), some coders may question whether concurrent care services can be reported. Frequently, coders assume that if a patient is in intensive care, he or she must be receiving critical care.

Although Medicare allows only one physician to report for a given hour of critical care, a second physician can report a subsequent hospital care code if he or she also provides care to a critically ill or injured patient. More than one physician can provide critical care services to a patient on the same day if the physicians meet the requirement for critical care services. They just cannot provide critical care during the same hour.

"This is where it is important for the doctors to document the time of the visits, because only one physician can provide critical care at a time," Revel says. If the physician seems to be performing a regular hospital visit while another is providing critical care because the documentation lacks time notations, insurance carriers will likely see the care as redundant and refuse to pay, she adds.

Remember that being in the ICU does not necessarily mean the patient is receiving critical care. If the patient is not undergoing critical care, Medicare places no restrictions on reporting concurrent care in the ICU, and you should report regular subsequent hospital care codes (99231-99233), says Teresa Thompson, CPC, a coding and reimbursement specialist based in Sequim, Wash.

Physicians and coders should be aware of the clear lines that payers draw between concurrent care and a consultation because inpatient consultations (99251-99255) have higher relative values than the corresponding subsequent hospital care codes. Medicare and CPT have the same three basic criteria for a consultation:

1. A request for a consultation from the patient's physician must be recorded in the patient's medical record.

2. The consultant must review the patient's medical condition.

3. The consulting physician must provide a written report of his or her findings to the requesting physician, which can be satisfied with the progress note written in the inpatient chart, because this chart is a shared medical record among all the physician specialists involved in patient care.

A consulting physician may initiate diagnostic and/or therapeutic services at the time of the evaluation or during a subsequent visit, and the service will be considered a consultation because no transfer of care occurs at the time of the evaluation request.