408 ||||||||||| APPENDIXES CPT copyright 2015 American Medical Association. All rights reserved. Appendix B Figure B-5. Global Per Diem Critical Care Codes: Direct Supervision and Reporting Guidelines The delivery of neonatal and pediatric critical care has undergone significant changes in the last 2 decades, incorporating expanded technology and services and new patterns of delivery of care. Neonatal intensive care units (NICUs) have grown dramatically as improvements in perinatal care have led to markedly improved survival rates of the small preterm neonate. There has also been a growing national population with major socioeconomic shifts. These changes have led to a large increase in NICU beds. Simultaneous to these demographic and epidemiologic changes, serious Accreditation Council for Graduate Medical Education and Residency Review Committee limitations in resident and fellow work hours and, more specifically, to those hours allocated to clinical care in the NICU have reduced the number of house officers providing neonatal critical care. There has been a rapid expansion of other neonatal providers working as a team in partnership with an attending physician to meet expanding bedside patient care needs. These nonphysician providers (NPPs by Centers for Medicare & Medicaid Services nomenclature) are primarily neonatal nurse practitioners (NNPs). They have assumed a critical role in assisting the attending physician in caring for this expanding population of patients. Neither NNPs nor resident/fellows are substitutes for the attending physician, who continues to remain fully in charge of these patients and directly supervises NNPs and resident/fellow physicians as well as other ancillary providers (eg, registered nurses, respiratory therapists, nutritionists, social workers, physical thera- pists, occupational therapists), who all play important contributory roles in the care of these critical patients. Unlike the supervision for residents/fellows enrolled in graduate medical education programs, the attending physician’s supervision and documentation of care provided by NNPs is not covered by Physicians at Teaching Hospitals (PATH) guidelines. The attending physician is not “sharing services” with the NNP or resident/fel- low. The attending physician (the physician responsible for the patient’s care and reporting the service for that date) remains solely responsible for the supervision of the team and development of the patient’s plan of care. In developing that plan, the attending physician will use the information acquired by and discussed with other members of the care team, including that of the resident/fellow and NNP. When supervising residents/fellows, the attending physician will use this collective information as part of his or her own documentation of care. The attending physician must demonstrate in his or her own note that he or she has reviewed this information, performed his or her own focused examination of the patient, documented any additional findings or disagreements with the resident’s/fellow’s findings, and discussed the plan of care with the resident/fellow to meet PATH guideline requirements. These rules allow the attending physician to use the resident/fellow note as a major component of his or her own note and in determining the level of care the attending physician will report for that patient on that date. Physicians at Teaching Hospitals guidelines do not apply to patients cared for by NNPs because NNPs are not enrolled in postgraduate education. This is true whether the NNP is employed by the hospital, medical group, or independent contractor. Centers for Medicare & Medicaid Services rules prohibit NPPs (in this case NNPs) and the reporting physician from reporting “shared or split services” when critical care services are provided. The reporting physician may certainly review and use the important information and observation of the NNPs, but the physician also provides his or her own evaluation along with documentation of the services he or she personally provided. Documentation expectations for the reporting physician include review of the notes and observations of other members of the care team an independent-focused, medically appropriate bedside examination of the patient and documentation that he or she has directed the plan of care for each patient whose services the physician reports. In many critically ill but stable patients, this requirement can be met by a single daily note. In situations in which the patient is very unstable and dramatic changes and major additional interventions are required to maintain stability, more extensive or frequent documentations are likely and may be entered by any qualified member of the care team. In some states, NNPs, through expanded state licenses, are permitted to independently report their ser- vices. If these NNPs are credentialed by the hospital and health plan to provide critical care services and pro- cedures and possess their own National Provider Identifier (NPI), they may independently report the services they provide. In these states they can function as independent contractors or as employees of the hospital or a medical group, reporting their services under their own NPI. It is important to emphasize again that the
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