Neurology & Pain Management Coding Alert

Insurers typically specify strict guidelines for payment of more than one service for the same patient on the same day, especially if two or more physicians work together to provide care. Nevertheless, physicians providing medically necessary "concurrent care" should expect full reimbursement for their services and can get it if they document thoroughly and assign ICD-9 codes appropriately. Defining Concurrent Care The Medicare Carriers Manual (MCM), section 2020 E, states, "Concurrent care exists where services more extensive than consultative services are rendered by more than one physician during a period of time." In other words, two or more physicians are actively involved in the patient's care, beyond the level of providing a written report of the patient's condition to a "requesting" physician. In addition, no transfer of care from one physician to another occurs. Rather, two or more physicians share responsibility for the patient, co-managing a single condition or (more commonly) tending to distinct, coexisting medical problems. Providers rendering concurrent care may include physicians, physician assistants, nurse practitioners, clinical nurse specialists, psychologists and others. The services may be inpatient or outpatient, but generally occur in an inpatient (facility) setting.

Note: Medicare allows as many as six different specialists to report concurrent care for a single patient. Private payers follow similar guidelines.

Demonstrate Necessity Insurers will not reimburse for unnecessary or redundant services. To gain payment for concurrent care, therefore, you must provide solid documentation to demonstrate medical necessity. According to the MCM, "To determine whether concurrent physicians' services are reasonable and necessary, the carrier must decide (l) whether the patient's condition warrants the services of more than one physician on an attending (rather than consultative) basis, and (2) whether the individual services provided by each physician are reasonable and necessary." The MCM goes on to note, "Correct coverage determinations can be made on a concurrent care case only where the claim is sufficiently documented for the carrier to determine the role each physician played in the patient's care."

To reach a payment decision, the payer will first consider the specialty of each physician to determine if the patient's diagnosis(es) requires (in Medicare's words) "diverse specialized medical or surgical services."

"For example, a primary-care physician [PCP] requests a consult for a patient with a suspected diagnosis of carpal tunnel [354.0]," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J. If the neurologist confirms the diagnosis, he or she will issue a report to the requesting physician, who will either initiate treatment or transfer care to the neurologist. "But a diagnosis of carpal tunnel alone would usually not justify both physicians' continuing involvement," she explains. A more complex diagnosis, such as [...]