Medicare Compliance & Reimbursement

MACs focus on diagnosis and specialty to differentiate concurrent care.

If you perform an E/M service for a patient on the same day as another physician, be certain that your claim is valid, medically necessary, and specialty specific or you run the risk of a denied claim.

Nuts and bolts: Concurrent care occurs when two physicians perform separate E/Ms on the same patient on the same date of service. If the patient’s condition warrants the care of two (or more) physicians, you’ll both be able to code for individual E/Ms based on encounter notes. There are several factors to consider before submitting these claims, particularly in regard to subsequent hospital care.

Remember: “Physicians can bill only one subsequent visit per day,” reminds Tamara Canipe, RN, clinical quality management coordinator with Palmetto GBA in a webinar on subsequent hospital care. She advises that you consider these rules on billing more than one physician visit per day:

• If all the physicians fall under the same specialty who visit the patient and administer subsequent hospital care on a particular day — CPT^® Codes 99231-99233 — then they must bill as one provider.
• There can only be one subsequent care E/M code paid per day no matter how many physicians treat a patient.
• The level of code must reflect the level of work from all the visits combined.
• The AI modifier (Principal Physician of Record) is only for the attending physician in the initial visit.
• Subsequent hospital care is not separately payable during a global surgery period “even when a bill is fragmented or a stage procedure.”

Case in point: Many components play into whether concurrent care is permissible under subsequent hospital visits. “The carrier will decide if concurrent care is covered,” says Canipe. However, if two different medical providers under different specialty codes see patients on the same day but for different conditions and offer different diagnoses with notes that explain the need for the visit, then both physicians may claim that they administered subsequent hospital care, she suggests.

Tip: On concurrent care claims, “be diligent in the reporting order of the diagnoses for each claim as well,” recommends Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, medical coding director at ACE Med Group in Pittsburgh, Pa.

Explanation: Let’s say one physician is treating condition A, and the other is treating condition B, but condition C is underlying. When coding for concurrent care, “condition C should not be the primary diagnosis for either service. The documentation should clearly illustrate the physician’s involvement with the patient, thus allowing for a clear illustration as to who is treating what [injury or illness],” continues Hauptman.