D. Concurrent care

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.