CPT copyright 2015 American Medical Association. All rights reserved. YOUR CODING TOOLKIT ||||||||||| 409 Appendix B Figure B-5. Global Per Diem Critical Care Codes: Direct Supervision and Reporting Guidelines, continued NNP and the physician do not report a shared critical care service. Critical care services are reported under the NNP or physician NPI, dependent on who was primarily providing the patient service and directing the care of the patient. Two providers may not report a global per diem critical care code (eg, 99468, 99469) on the same date of service. In most situations, the physician is serving as responsible and supervising provider and the NNP (employed by the group or hospital) is acting as a member of the team of providers the physician supervises. Physician Supervision Current Procedural Terminology (CPT®) states that codes 99468–99476 (initial and subsequent inpatient neonatal and pediatric critical care, per day, for the evaluation and management of a critically ill neonate or child through 5 years of age) are used to report services provided by a physician directing the inpatient care of a critically ill neonate or young child. Current Procedural Terminology makes clear that the reporting provider is not required to maintain 24-hour, in-hospital physical presence. Current Procedural Terminology notes that the physician or other reporting provider must be physically present and at bedside at some time during the 24-hour period to examine the patient and review and direct the patient’s care with the health care team. The physician must be readily available to the health care team if needed but does not have to provide 24-hour, in-house coverage. One provider reports the appropriate code only once per day, even though multiple pro- viders may have interacted with the patient during the 24-hour global period (eg, on-call physician, NNP). Medical Record Documentation The medical record serves the dual purpose of communicating the medical status and progress of the patient and documenting the work of the reporting provider. Based on the information presented previously, it is the suggestion of the American Academy of Pediatrics Committee on Coding and Nomenclature that the medical record documentation by the reporting physician or NPP supporting critical care codes should contain at a minimum Documentation of the critical status of the infant or child (This is not to be inferred.) Documentation of the bedside direction and supervision of all aspects of care Review of pertinent historical information and verification of significant physical findings through a medi- cally indicated, focused patient examination Documentation of all services provided by members of the care team and discussion and direction of the ongoing therapy and plan of care for the patient Additional documentation of any major change in patient course requiring significant hands-on interven- tion by the reporting provider The following are not required of the reporting physician or NPP: Twenty-four–hour presence in the facility or bedside Two or more documented notes a day Personally ordering all tests, medications, and therapies Performing all or any of the bundled procedures Documenting a daily comprehensive physical examination Documenting stable or unstable status so long as the infant or child meets critical care criteria Each patient has a different level of illness(es), grouping of diagnoses, and medical and socioeconomic problems. The following are only examples of notes and should not be interpreted as requirements in every note for each patient: A. The following note represents a sample attestation that could be appended to a resident or fellow’s prog- ress note: “I have reviewed the resident’s progress note and the baby has been seen and examined by me. He continues to be critically ill with respiratory failure requiring mechanical ventilation. I concur with the resi- dent’s evaluation and findings, though I did not appreciate abdominal tenderness on examination. I have discussed and agreed on a plan of care with the resident.”
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