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Figure B-7. 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/ fellow.
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 pro-
vided. 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 services.
If these NNPs are credentialed by the hospital and health plan to provide critical care services and procedures
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 NNP