Concurrent care exists where services more extensive than consultative services are
rendered by more than one physician during a period of time. The reasonable and necessary
services of each physician rendering concurrent care could be covered where each is
required to play an active role in the patient's treatment, for example, because of
the existence of more than one medical condition requiring diverse specialized medical
services.
To determine whether concurrent physicians' services are reasonable and necessary,
the carrier decides (1) whether the patient's condition warrants the services of more
than one physician on an attending (rather than consultative) basis, and (2) whether
the individual services provided by each physician are reasonable and necessary.
While it would not be highly unusual for concurrent care performed by physicians in
different specialties (e.g., a surgeon and an internist) or by physicians in different
subspecialties of the same speciality (e.g., an allergist and a cardiologist) to be
found reasonable and necessary, the need for such care by physicians in the same specialty
or subspecialty (e.g., two internists or two cardiologists) would occur infrequently
since in most cases both physicians would possess the skills and knowledge necessary
to treat the patient. However, circumstances could arise which would necessitate such
care. For example, a patient may require the services of two physicians in the same
specialty or subspecialty when one physician has further limited practice to some
unusual aspect of that specialty, e.g., tropical medicine. Similarly, concurrent services
provided by a family physician and an internist may or may not be found to be medically
necessary, depending on the circumstances of the specific case. If it is determined
that the services of one of the physicians are not warranted by the patient's condition,
payment may be made only for the other physician's (or physicians') services.
Once it is determined that the patient requires the active services of more than one
physician, the individual services must be examined for medical necessity, just as
where a single physician provides the care. For example, even if it is determined
that the patient requires the concurrent services of both a cardiologist and a surgeon,
payment may not be made for any services rendered by either physician which, for that
condition, exceed normal frequency or duration, unless, of course, there are special
circumstances requiring the additional care.
The carrier must also assure that the services of one physician do not duplicate those
provided by another, e.g., where the family physician visits during the post-operative
period primarily as a courtesy to the patient.
Hospital admission services performed by two physicians for the same beneficiary on
the same day could represent reasonable and necessary services, provided, as stated
above, that the patient's condition necessitates treatment by both physicians. The
level of difficulty of the service billed for may vary between the physicians, depending
on the severity of the patient. For example, the admission services performed by a
physician who has been treating a patient over a period of time for a chronic condition
would not be as involved as the services performed by a physician who has had no prior
contact with the patient and who has been called in to diagnose and treat a major
acute condition.
A correct coverage determination can be made on a concurrent care case only where
the claim is sufficiently documented for the carrier to determine the role each physician
played in the patient's care (i.e., the condition or conditions for which the physician
treated the patient). If in any case the role of each physician involved is not clear,
the carrier requests clarification.