- The condition(s) or diagnoses warrant the service and the specialty or expertise of the other physician(s) and at a reasonable frequency or duration.
- Duplicate services (i.e., services provided by two different providers of the same specialty for the same or similar conditions) will typically not be considered necessary unless a special circumstance is noted. For many payers, the internist and subspecialist who co-manage the same problem may have services performed on the same day denied, and documentation would need to show there were “special circumstances.” However, if the hospitalist is treating additional issues, then there should be no problem with separate payment. Medicare does recognize the endocrinology and internal medicine specialties separately and would probably pay both even if for the same condition. But if both are really “co-managing” the same problem without any additional issues daily, most payers are going to question this, either at the time of billing or retrospectively through audits.
Inpatient Concurrent care then is coded with subsequent hospital codes in the hospital setting (Codes 99231 through 99233).
Scenario # 3
A 73-year-old man with a past medical history notable for chronic renal insufficiency, hypertension, and Alzheimer’s type dementia undergoes a right open nephrectomy for renal cell carcinoma. His early postoperative course is marked by hypotension in the post-anesthesia care unit, and he is admitted to the SICU. His course there is significant for worsening of his baseline creatinine of 1.9 to 3.8, the development of delirium, and labile blood pressure. He is transferred from the SICU to a regular nursing floor on postoperative day 2, and the attending urologist requests that you assume management of the patient’s hypertension, delirium, and acute renal failure.
Question: Does this meet the definition of appropriate concurrent care or a consultation?
Answer: Although this constitutes something of a gray area, the request as worded indicates that the hospitalist will be providing concurrent care, and the initial visit should thus be billed as a Level 3 subsequent visit (99233). If the hospitalist’s role is, rather, to provide recommendations regarding management of these problems, the initial visit should be billed as an initial inpatient consult at the appropriate level.
Scenario # 4
A 66-year-old woman with a history of coronary artery disease 3 years after stenting of the left anterior descending coronary artery, moderate aortic stenosis, well-controlled diabetes mellitus, and hyperlipidemia undergoes a left modified radical mastectomy. On the morning of her first postoperative day, she experiences substernal chest pain, with T wave inversions in the inferior leads of her ECG. Her breast surgeon consults cardiology for her chest pain, endocrinology for “diabetic control,” and the hospitalist to “oversee the medical issues.”
Question: Can the hospitalist successfully bill in this setting? If so, what needs to be done to allow this?
Answer: Because of the various specialists who are treating this patient’s medical conditions, it will be difficult to demonstrate to a payer that an additional physician should be managing the patient’s care on a daily basis for the same medical problems. Such billing would probably be considered “duplicate care” and one of the physicians’ charges will be appropriately denied. However, if the specialists have been consulted only and have not assumed management for these medical conditions, then the hospitalist who has assumed management may bill for these services. As with scenario #3, the surgeon’s request as worded in this scenario indicates the hospitalist is providing concurrent care and a consultation is not being requested.
Scenario #5:
The hospital medicine consult team is asked to see a 31-year-old woman who is postoperative day 3 after a total proctocolectomy for refractory ulcerative colitis. Her past medical history is remarkable for iron-deficiency anemia, steroid-induced diabetes, and depression. You are asked to evaluate the patient for shortness of breath that began that day. The PGY-3 resident working with you evaluates the patient initially, reviews all available records from this admission as well as the past, performs an exhaustive history and physical, personally reviews the ECG and chest X-ray that have just been completed, and documents all of the above. You then discuss the case with the resident, and personally confirm critical portions of the history and examination. You agree with the resident’s assessment that the patient has most likely sustained a pulmonary embolism, as well as her recommendation for empiric anticoagulation and an urgent V/Q scan.