Navigating the complexities of medical billing often involves understanding nuanced coding scenarios. One such scenario is concurrent care, a situation that arises when a patient receives services from more than one physician during the same period of care. Accurate coding for concurrent care is crucial for proper reimbursement and compliance. This guide will delve into what concurrent care means in CPT (Current Procedural Terminology) coding, how it differs from duplicative care, and best practices for ensuring accurate claim submissions.
Defining Concurrent Care in Medical Coding
Concurrent care, in the context of medical coding, refers to a specific situation where a patient receives medically necessary services from more than one physician, each providing distinct and specialized care for the patient’s various medical conditions during the same episode of illness or injury.
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.”
It’s essential to distinguish concurrent care from duplicative care. Duplicative care occurs when multiple physicians provide similar services to a patient, often addressing the same medical condition, which is generally not considered medically necessary and is not reimbursable.
Key questions to differentiate concurrent care from duplicative care:
- Is the involvement of multiple physicians medically necessary? Does the patient’s condition necessitate the expertise of more than one physician acting in an attending role, rather than a consultative one?
- Are the services provided by each physician “reasonable and necessary”? Are each physician’s services distinct and required for the management of different aspects of the patient’s health?
If you can answer “yes” to both of these questions, you are likely dealing with a concurrent care scenario. If the answer to either question is “no”, the services might be considered duplicative.
When Does Concurrent Care Apply in CPT Coding?
Concurrent care can manifest in various clinical scenarios. Here are a few examples to illustrate when concurrent care coding is appropriate:
1. Multiple Medical Conditions:
Consider a patient hospitalized due to complications from thyroid surgery. An otolaryngologist manages the surgical complications and requests a pain management specialist to address the patient’s severe post-operative pain. In this case:
- The otolaryngologist provides initial hospital care for surgical complications. For example, they might report CPT code 99222 (Initial hospital care, per day, for the evaluation and management of a patient…).
- The pain specialist provides an inpatient consultation to manage the complication-related pain. They might report CPT code 99253 (Inpatient consultation for a new or established patient…).
Both physicians are delivering concurrent care, focusing on different aspects of the patient’s health – surgical recovery and pain management – arising from the same underlying situation.
2. Different Specialties, Same Practice:
Concurrent care can even occur when physicians from the same specialty or within the same medical practice are involved. Imagine a patient with both a fractured jaw and a nasal fracture.
- Surgeon A, specializing in jaw injuries, treats the fractured jaw.
- Surgeon B, specializing in nasal injuries, treats the nasal fracture.
Even though they might be from the same practice and specialty (e.g., oral and maxillofacial surgery), their distinct expertise and treatment of different injuries arising from the same incident can constitute concurrent care.
3. Same Diagnosis, Different Focus:
Interestingly, concurrent care doesn’t always require different diagnoses. Two physicians might treat a patient for the same underlying condition but focus on different facets of the patient’s care. In such cases, it is critical to ensure documentation clearly justifies the medical necessity for both physicians’ involvement.
The Crucial Role of Documentation in Concurrent Care
Robust documentation is paramount for successful concurrent care claim submissions. Payers will scrutinize these claims to ensure the services are indeed concurrent and not duplicative. Detailed and accurate clinical notes are your best defense against claim denials.
Key documentation elements for concurrent care:
- Clearly state the medical necessity for each physician’s involvement. Explain why each physician’s specialized expertise is required for the patient’s care.
- Detail the distinct services provided by each physician. The documentation should clearly differentiate the roles and responsibilities of each provider in the patient’s overall treatment plan.
- Specify the diagnoses being addressed by each physician. While not always different, clearly linking each physician’s service to a specific condition or aspect of the patient’s health is vital.
- For same-diagnosis scenarios, provide a thorough explanation in the clinical record justifying the medical necessity of concurrent care. Explain why the patient requires treatment from two physicians for what appears to be the same condition.
By meticulously documenting the medical necessity and distinct nature of each physician’s services, you can confidently and accurately report concurrent care in CPT coding, ensuring appropriate reimbursement and adherence to coding guidelines. Remember, clear and comprehensive documentation is the cornerstone of compliant and successful medical billing practices, especially in complex scenarios like concurrent care.
