Coding & Reimbursement

Clarifying the Rules for Concurrent Care

By Suzanne L. Corcoran, COE

Medicare has rules for concurrent care, when more than one physician sees a patient on the same day. But they can be confusing for physicians and staff. Here I'll try to provide some clarity.

Q. What is concurrent care, and when do the rules apply?

A. Medicare's instructions in the Claims Processing Manual state, “If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or physicians in the same specialty in the same group, only one evaluation and management service may be reported unless the … services are for unrelated problems.” (MCPM Chap 12 §30.60.5). It is commonly accepted that the ophthalmology exam codes (920xx) follow the same rules.

Q. Is payment allowed for more than one office visit per day for Medicare beneficiaries?

A. Sometimes. If the providers involved are either of different specialties or in different practices, multiple visits on the same day are not likely to be questioned. However, concurrent care rules come into play if multiple patient encounters are billed for a single patient from physicians in a group practice.

Q. How are two visits within the group, for different conditions, documented to support separate claims? How do we bill?

A. When a patient presents with multiple conditions requiring evaluation by two different ophthalmologists in the group, careful documentation is necessary to support separate claims. Each physician should have his or her own progress note—usually documented on separate pages in the record. A single entry in the chart signed by both providers does not adequately support separate charges.

On occasion, a patient is seen by more than one doctor in the group on the same day for scheduling reasons, or because the doctors do not want the second exam to be delayed. Because only a single claim for an exam may be submitted, physicians should select a level of service representative of the combined visits and submit the appropriate code for that level (MCPM Chap 12, §30.60.5).

Remember that physicians are not identified by subspecialty training. Medicare recognizes all ophthalmologists under specialty number 18, without distinction to fellowship training or special areas of interest. The concurrent care rule will apply and limit the practice to a single claim for an office visit.

Q. If only one claim is permitted, which physician should bill?

A. Either physician may be listed on the claim as long as the medical record clearly shows his or her involvement in the care. In many practices, the claim is billed under the provider who made the final diagnosis and initiated the treatment plan.

Q. If a patient is referred for a same-day visit from another ophthalmologist in town, may both visits be billed?

A. Yes. This restriction applies to providers in the same group practice.

Q. Does this rule also apply to optometrists?

A. Yes and no. If two optometrists in the same practice examine a patient on the same day, then only one claim is expected. If an optometrist and an ophthalmologist in the same practice both examine a patient and document separate exams, they may each submit a claim for reimbursement. Because ophthalmology and optometry are distinct specialties, the rules differ.

Examples:

A patient with keratoconus is being followed by Dr. A, a general ophthalmologist. On today's visit, the corneal thinning has progressed to the point where surgery is considered and a penetrating keratoplasty is recommended. Dr. A asks his partner, the cornea specialist of the practice, to evaluate the patient. She examines the patient, confirms the diagnosis and plans surgery.

Two ophthalmologists in the same group practice examined this patient for the same reason. Only one office visit should be billed, so select the visit code that is equal to the work provided by both physicians combined.

Another patient presents in your office for a previously scheduled retina follow-up for AMD. She is also being treated by her primary care provider for shingles on her scalp and face. Just this morning, she woke with new blisters on her left eyelid and a red, painful left eye. The retina specialist examines her for the AMD but asks the cornea specialist to evaluate the left cornea for herpetic keratitis.

Even though two ophthalmologists examined the patient on the same day, the exams were for unrelated conditions. Each ophthalmologist should submit a claim for reimbursement. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.