Page 15 - Medicare Benefit Policy Manual

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
sub-specialty when one physician has further limited his or her 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 reasonable and
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 there are special circumstances requiring the
additional care.

The A/B MAC (B) 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 provided may vary between the physicians, depending on the
severity of the complaint each one is treating and that physician’s prior contact with 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/B MACs (B) should have sufficient means for identifying concurrent care situations.
A correct coverage determination can be made on a concurrent care case only where the
claim is sufficiently documented for the A/B MAC (B) 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 A/B MAC (B) should request clarification.