physician billing - Concurrent care

Concurrent Care 

Concurrent care exists when certain evaluation and management (E/M) services are rendered by more than one physician with the same or similar specialty on the same date of service. Reasonable and necessary services of each physician rendering concurrent care could be covered when each is required to play an active role in the patient ’ s treatment -- for example, due to the exis- tence of medical conditions requiring diverse specialized medical services. 

To find concurrent physicians ’ services reasonable and necessary, the carrier must determine:

* If the patient ’ s condition warrants the services of more than one physician, with the same or simillar specialty, on an attending (rather than consultative) basis; and

* If the individual services provided by each physician are reasonable and necessary. 

Before determining payment, carriers consider the physician ’ s specialty, as well as the patient ’ s diagnosis.

Physician specialties indicate the necessity for concurrent services, but the carrier ’ s medical staff must also consider the patient ’ s condition and the inherent reasonableness and necessity of the services. For example, although cardiology is a sub specialty of internal medicine, the treatment of both diabetes and a serious heart condition might require the concurrent services of two physicians, each practicing in internal medicine but specializing in different sub specialties.

A patient may occasionally require the services of two physicians with the same specialty or subspecialty, if one physician has limited his or her practice to a unique aspect of that specialty. If the medical documentation does not substantiate the need for more than one physician ’ s service, payment will not be made for the other physician ’ s services.


CONCURRENT CARE - INPATIENT

Inpatient concurrent care is defined as the provision of services by more than one physician to the same patient on the same day.

Inpatient Concurrent Care (Age 21 and over)

In the near future, the system changes to allow reimbursement for up to 3 medically necessary hospital visits for adults to providers of different specialties/subspecialties will be complete. Please monitor the Louisiana Medicaid website, remittance advice messages, and Louisiana Medicaid Provider Update for updated information.



Inpatient Concurrent Care (Under Age 21)

In order to qualify for concurrent care, a patient must have a condition(s) or a diagnosis(es) which requires the services of a physician(s) whose specialty, in the majority of cases, is different from that of the primary care physician. Additionally, the patient’s condition(s) or diagnosis(es) must be of such severity and/or complexity that the medical community would consider the rendering of concurrent care to be reasonable and warranted. It must be expected that the request by the primary care physician for the provision of concurrent care services would be upheld by peer review. In all cases, concurrent care must be medically necessary, unduplicative, and reasonable. All claims are subject to post-payment review.

• Concurrent care for simple outpatient surgical procedures and uncomplicated diagnoses is not covered.

• Concurrent care policy does not apply to state-funded foster children.

• Concurrent care of patients in the intensive care areas of the hospital is allowed.

• Concurrent care by more than one provider of the same specialty will be sent to medical review prior to reimbursement. In these cases, a request for, and a review of the medical documentation will occur before the decision to authorize payment is 
made.

• Providers may bill only one hospital visit per day per recipient, even if the patient must be seen more than once daily. The level of code billed for that date should reflect all the services rendered that day.

• Hospital discharge day management codes should be billed on the date of discharge. Each concurrent care provider will be reimbursed for the services on the date of discharge, as long as his specialty is different from those of the other concurrent care providers.

• The patient’s hospital records must be available for review, should it be necessary to substantiate the need for concurrent care.


Consultants and Inpatient Concurrent Care

A consultant may become a concurrent care provider on a case if his/her services after the consultation are necessitated by the condition of the patient, and meet the reasonableness test for standard of care. The consultant may bill for the initial consultation (if it meets the definition of a consultation described in the “Consultations” section of this manual), but not for additional consultations, as he/she cannot be both a consultant and a concurrent care provider on the same case. 

Subsequent care after the initial consultation should be submitted as the appropriate level hospital inpatient service.

If, after consultation, the surgeon’s role is assumed by the consultant, the consultant may bill for neither additional consultations nor follow-up care, as the global surgery period policy (GSP) supersedes this policy.


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