Navigating the complexities of Evaluation and Management (E/M) coding can be challenging, especially when multiple physicians are involved in a patient’s care. Concurrent care, where more than one physician actively manages a patient’s distinct medical conditions, adds another layer of intricacy. Accurate coding is crucial for proper reimbursement and compliance. This guide provides essential Concurrent Care Coding Tips to help you confidently and correctly report these services.
Understanding Concurrent vs. Duplicative Care
Before delving into the specifics, it’s vital to differentiate between concurrent care and duplicative care. The Centers for Medicare & Medicaid Services (CMS) defines concurrent care as “reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient’s treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services.”
In essence, concurrent care applies when each physician addresses a different aspect of the patient’s health due to multiple medical conditions. Conversely, duplicative care occurs when multiple physicians provide the same or overlapping services, which is generally not reimbursable.
To determine if care is concurrent rather than duplicative, consider these key questions:
- Does the patient’s condition necessitate the active involvement of more than one physician in an attending capacity, rather than consultation?
- Are the services provided by each physician both reasonable and medically necessary for the patient’s specific needs?
Affirmative answers to both questions typically indicate concurrent care. If either answer is negative, the services likely fall under duplicative care.
When coding for concurrent care, remember to prioritize accurate diagnosis coding. As Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med, points out, the primary diagnosis for each physician’s claim should reflect the condition they are actively treating, not an underlying condition being managed by another physician. Clear documentation is essential to support the distinct roles of each physician in the patient’s care.
Diagnosis Coding Nuances in Concurrent Care
Concurrent care often arises when a patient presents with multiple health issues requiring different specialists. Consider a patient initially seen by a primary care physician for a respiratory infection who also has a pre-existing heart condition managed by a cardiologist. Both physicians may be providing active treatment concurrently, each focusing on their respective area of expertise.
For example, imagine a patient hospitalized for complications following cardiac surgery. A cardiologist is managing the patient’s cardiovascular health, while a nephrologist is consulted to address acute kidney injury that developed post-surgery.
Cardiologist Coding: The cardiologist might report an appropriate level of initial hospital care code (99221-99223) based on the complexity of managing the patient’s cardiac condition.
Nephrologist Coding: The nephrologist, acting as a consultant, would report an inpatient consultation code (99252-99255) reflecting the evaluation and management of the acute kidney injury. Crucially, the documentation would specify the nephrologist’s role as a consultant requested by the cardiologist.
In this scenario, both physicians are delivering concurrent care, each addressing a distinct medical issue within the same patient encounter. It’s important to note that concurrent care can also occur even when physicians share the same specialty or are within the same practice. For instance, in a large orthopedic group, one surgeon might specialize in hip replacements while another focuses on knee arthroscopy. If a patient requires both procedures, performed by different surgeons within the same group, this could also be considered concurrent care.
Concurrent Care for the Same Condition
Interestingly, concurrent care isn’t limited to situations involving different diagnoses. Two physicians can provide concurrent care while treating the same condition, billing the same ICD-10 code. This often happens when physicians from different specialties bring unique expertise to manage a complex medical problem collaboratively.
Consider a patient with a severe stroke. A neurologist might lead the overall management of the stroke, while a physiatrist focuses on rehabilitation and functional recovery from the stroke’s effects. Both physicians are treating the sequelae of the stroke (and thus potentially using similar ICD-10 codes related to stroke), but their services are distinct and necessary for comprehensive patient care.
In such cases, detailed documentation becomes paramount.
The Power of Detailed Documentation in Concurrent Care Claims
Robust documentation is the cornerstone of successful concurrent care claims. When submitting claims for concurrent care, especially when using the same ICD-10 codes, comprehensive clinical notes are your best defense against potential payer scrutiny.
Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated, emphasizes that “two physicians treating a patient for the same condition and submitting claims with the same ICD-10 codes [should] fully explain the circumstances in the clinical record.”
Clear and thorough progress notes should articulate:
- The specific medical necessity for each physician’s involvement.
- The distinct focus of each physician’s treatment and management plan.
- How each physician’s services contribute uniquely to the patient’s overall care.
- Communication and coordination between the physicians, if applicable.
By providing a complete and detailed clinical picture, you proactively address potential payer questions about whether the care is truly concurrent or merely duplicative. Solid documentation substantiates the medical necessity and distinct nature of each physician’s services, maximizing the likelihood of claim approval and appropriate reimbursement.
Conclusion: Code Concurrent Care with Confidence
Mastering concurrent care coding requires a clear understanding of its definition, careful attention to diagnosis coding, and, above all, meticulous documentation. By adhering to these concurrent care coding tips, healthcare providers and coding professionals can confidently and accurately bill for medically necessary services when multiple physicians are actively involved in a patient’s care. This ensures both compliance and appropriate reimbursement for the valuable expertise each physician brings to the patient’s treatment journey.
