Correspondence

Medicare and Payment for Concurrent Care

N Engl J Med 1994; 331:1025-1026October 13, 1994

Article

To the Editor:

Policies proposed by the Health Care Financing Administration (HCFA) are threatening the process by which a primary care physician admits a Medicare patient with multiple illnesses to the hospital and uses knowledge of the patient's medical history and social situation to deal with the patient's current illness while coordinating suggestions made by consultants for specific problems. When the primary care physician receives advice from a cardiologist and neurologist for a patient with cardiac and neurologic disease and discusses the implications of the advice with the patient and his or her family, all three physicians bill Medicare for each day that they see the patient. This is known as concurrent care -- that is, care administered by two or more physicians on the same day for the same diagnosis.

Concurrent care is no longer paid for by Medicare. The first physician to submit the bill to Medicare is paid and the second physician receives no payment, regardless of the extent of his or her participation in the patient's care. A patient in the intensive care unit can be asked to sign a waiver assuming responsibility for the charges in lieu of Medicare payment. Medicare suggests that the consultant submit charges with a consultation code, after which the consultant is allowed two more visits per week. If a primary care physician is caring for a patient with a myocardial infarction and the cardiologist believes that he or she needs to see the patient more than two times a week, the primary care physician must not see the patient on those additional days.

If new general medical problems develop on a day when the patient is not seen by the primary care physician, the cardiologist can deal with the problems or defer to the primary care physician, who could have seen the patient had he or she known that the problems would occur. Instead of coordinating the suggestions of specialists, the primary care physician has to keep track of who sees the patient and try to have each specialist come two days a week.

The very ill patient who hopes his or her physicians are working together on the medical problems may find that the physicians are trying to decide who should see the patient on which days, to comply with Medicare regulations. A cost-saving solution is to have physicians see their hospitalized patients free of charge.

The proposed concurrent-care regulations limit the coordination of care among physicians and interfere with the continuity of care.

Ira D. Mickenberg, M.D.
205 Main St., S., Southbury, CT 06488

Author/Editor Response

A spokesperson for the HCFA replies:

To the Editor: One area of Medicare coverage that is of particular concern to physicians is concurrent care, which occurs when two or more physicians bill for multiple visits during a patient's hospital stay. Medicare carriers have had flexibility in developing claims-processing screens, resulting in substantial perceived variation in both the scope and the consistency of the concurrent-care policy nationwide.

The Medicare law provides for coverage of services that are medically necessary for the diagnosis and treatment of a patient's illness or injury. Medicare coverage, when appropriate, includes consultative, as well as concurrent, care. Consultations are covered when they are furnished at the request of the attending physician and are medically necessary for the patient. They are generally limited to evaluative services, in which a course of clinical management is suggested to the attending physician. This does not include active and ongoing personal management of a patient's care by the consultant. Consultations are typically billed according to the consultation codes listed in the American Medical Association's Current Procedural Terminology, fourth edition (CPT-4).

Concurrent care, in contrast, is paid for by Medicare when the services of more than one physician are needed on an active daily basis. Typically, such care occurs because the patient has more than one condition requiring specialized services. An example is a victim of severe trauma who must be followed daily by specialists in orthopedics, neurosurgery, and general surgery. Proof that the services of one physician do not duplicate those of another lies in the degree and kind of care associated with a particular case. When the medical need for concurrent care is reflected in the documentation, Medicare covers and pays for the services. These services should be billed according to hospital evaluation-and-management visit codes (not consultation codes), as listed in CPT-4.

At the request of many physicians and organizations of physicians, the HCFA is reconsidering its approach to concurrent care. As part of our effort to improve the quality of our administrative services, we have been working with the medical directors of Medicare carriers and advisory committees to develop rules of coverage of concurrent care that are fair and consistent. We also plan to ask our Practicing Physicians Advisory Council to advise us about these issues in meetings scheduled for later this year. In the meantime, physicians providing concurrent care should continue to document carefully their respective roles in treating patients. By working together, HCFA and the medical community will ensure that beneficiaries receive clinically appropriate, and affordable, medical care.

Bruce C. Vladeck, Ph.D.
Health Care Financing Administration, Washington, DC 20201