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Concurrent CareConcurrent care is care provided to patients on a single date of service, for the same diagnosis, by several physicians within the same or similar specialties. Some carriers refer to this as duplicate care even though they are aware that physicians provide specialized care for specific reasons. Documenting the medical necessity for all services will facilitate rightful payment for quality medical care.
To improve documentation of medical necessity and the quality of care provided to all patients, the following suggestions for Evaluation and Management (E&M) service codes should be reflected in the medical record:
Document signs or symptoms presented by the patient at the time of service;
Document the actual services provided to the patient;
Document requests for consultations from other physicians in the medical record. Include the patient’s presenting sign or symptom that warrants the consult;
Document physician physical presence for all procedures that are submitted for billing;
Document the total amount of time spent with each patient. (Recording the time of day that the service was provided maybe helpful in demonstrating medical necessity.)
The specific ICD diagnosis code(s) must be recorded accurately, reflecting the documentation that memorializes the professional services provided.
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