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Confused when billing concurrent care?
When using consultants, spell out your expectations

Keywords: ICD-9 codes: Billing for concurrent care is risky -- manage consults to avoid denial of claims


by David Frenz, MD, and Sue A. Lewis, RN, CPC, PCS



Published in the February 2010 issue of Today's Hospitalist

GIVEN THE MEDICAL COMPLEXITY of most inpatients, hospitalized patients often need multiple physicians involved in their care. Having a roster of doctors likely improves clinical quality, but this division of labor poses several problems, particularly when it comes to coding and billing.

Concurrent care is defined as the provision of similar servicesófor example, more than one subsequent hospital visitóto the same patient by more than one physician on the same date. Physicians risk denial of claims and loss of revenue if third-party payers consider any of these billed services to be
There is no ICD-9 code for quarterback.

duplicative. Thatís why itís imperative for hospitalists to understand how to bill for concurrent care and structure their clinical activities appropriately.

Billing for more than one hospitalist
Problems with billing concurrent care can occur when more than one member of your hospitalist group sees a patient on a given day.

Your group can bill only one claim that day for that patient because all the hospitalists in the group are covered by one tax ID number and all work in the same specialty. Be sure to combine all group services on any one calendar day into one charge.

There is one caveat: Members of the same group and same specialty can submit different claims for the same patient on the same day if those visits are for unrelated problems. An example would be a patient who develops a new or different diagnosis that hasnít previously been documented or treated during the inpatient stay.

Say hospitalist A rounds in the morning on a patient being treated for heart failure who, later in the day, fallsó and is then seen by hospitalist B for head trauma. Clearly, this doesnít happen often, so most claims from group members wouldnít apply.

Adding consultants to the mix
When consultants are involved, however, billing for concurrent care can be trickier. You can certainly have more than one provider involved in a patientís care as long as certain criteria are met:

  • The care provided is medically necessary based on the patientís clinical presentation.

  • Each provider is actively managing a separate problem or condition.

  • Each provider bills for his or her services using diagnosis codes for the problem or condition that he or she is managing or treating.

Claims submitted by multiple providers will likely be denied if providers use the same primary diagnosis code on the same date of service.

This all seems straightforward until you start considering real-world examples. Take Ms. Jones, a 75-year-old female admitted through the emergency room for decompensated heart failure. She also has a history of chronic kidney disease and presents to the hospital with acute renal failure. The admitting hospitalist consults the cardiology and nephrology services for assistance with management.

If the cardiologist and nephrologist continue to follow the patient, they will presumably each bill for heart failure and kidney diseases, respectively, as their primary diagnoses. These diagnoses are no longer live options for the hospitalist, and the hospitalistís daily note will need to reflect services for a different primary condition.

Although Ms. Jones might have other problemsósay, atrial fibrillation and hyperkalemiaóone could reasonably speculate that these are related to the conditions being managed by the subspecialists and donít require additional physicians. The hospitalist may have effectively consulted him- or herself out of business.

No way to bill "team leader"
But doesnít Mrs. Jones need an attending physician to coordinate care and manage care progression? Sure, but thereís no ICD-9 code for quarterback. In this scenario, unless the patient has some other medical condition that requires hospitalist oversight, hospitalists just have to accept the fact that they canít bill for services rendered on the same day as cardiology and nephrology management.

So, what to do? Unfortunately, there is an unavoidable tension between our fiduciary obligation to patients and the need to make a living. The former always trumps the latter, which means that Ms. Jones gets her cardiology and nephrology consultations and the hospitalist possibly forfeits some income. Providing unnecessary medical services is fraud, but withholding necessary medical services is negligence.

Avoiding patient hijackings
There may be a middle way. The best solution is probably to have a conversation with the consultants. Remember, a consultation is a request to another provider who has more expertise in a given area and can offer advice and recommendations about a specific problem. Once the consultant has completed an initial evaluation and made treatment suggestions, the hospitalist can determine who should continue to follow the patient for that problem.

This might put you on a collision course in hospitals where consultation requests are construed as transfers of care, and specialists continue to round on patients after their initial evaluation. Hospitalists may need to politely hint to consultants that they "need a little help" or "some direction" to prevent surreptitious patient hijackings.

Alternatively, the hospitalist can outright signal that the consultation request is time-limited: "Could you please round for the next two days until things straighten out?"

Most consultants will appreciate clarification concerning their role. If the hospitalist wants the consultant to continue to manage a specific problem, the hospitalistís progress note should indicate that the consultant will be following the patient for a particular condition, indicating a transfer of care for that problem.

If, however, the hospitalist reviews the consultantís recommendations and decides to take care of the diagnosis, he or she does not need to document anything further. That can be tricky when consultants manage a patient for a few days and then transfer care back to the hospitalist when a condition appears to be resolving. Good consultants, however, will write "will sign off for now" in their notes, indicating that the hospitalist now has responsibility for that diagnosis.

David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. He serves as system medical director for addiction medicine and can be reached at dafrenz@healtheast.org. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care.
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