Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 25, 2006 PDF

For coordinating physician, underlying diagnosis may be key to payment

When two physicians treat the same problem concurrently in the hospital setting, it can be tricky to make sure both physicians get paid. (See PBI, Vol. 5, No. 41.) But it can be even trickier when a primary care or trauma physician coordinates a patient's care.

Example: A patient comes into the emergency room after a car accident. A trauma surgeon is called in to look after the patient, but the patient doesn't require surgical care. The patient does need an orthopedist and a neurologist, so the trauma surgeon calls the specialists in and stays to coordinate them.

"He can't just sign off on that patient because that patient was put under his care," explains Suzan Hvizdash, a physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. Many hospitals have a rule stating that a doctor can hand off a patient to a single specialist. But if the doctor sends the patient to more than one specialist, the referring doctor has to stay and coordinate.

So the trauma surgeon needs to stay and coordinate the patient's care, making sure the neurologist and orthopedist show up on time and play their parts.

Problem: The Medicare Claims Processing Manual states that two physicians can't be paid for treating the same problem concurrently. Coordination "may not be medically necessary from an insurance perspective, but it would be medically liable from a hospital perspective," says Hvizdash.

Solution: "If you can document that you're providing care of the patient that's distinct and different from what the other colleague is doing, you're going to both get paid," says Bruce Rappoport, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz in Fort Lauderdale, FL.

For example, the coordinating physician may be making sure the patient stays hemodynamically stable, says Hvizdash. Or if the patient has atrial fibrillation and needs to be monitored, the coordinating physician could bill for that.

It's also crucial to make sure that the specialists only bill for their own specialty-specific diagnosis codes and allow the coordinating physician to bill for whatever general problems she's treating, such as shock or internal bleeding, says Arlene Morrow, president of AM Associates in Tampa, FL.

Warning: You can't invent a service for your coordinating physician to bill for. If the doctor really isn't treating any problems that the specialists aren't treating, then it would be fraudulent to pretend otherwise.

Opportunity: In many cases your coordinating physician will provide the patient's follow-up care, which you can bill for. For instance, the orthopedist might come in and treat a fracture but leave the follow-up to the coordinating physician, notes Morrow.