Appendixes CPT copyright 2020 American Medical Association. All rights reserved. =New code ▲=Revised code #=Re-sequenced code +=Add-on code Global Per Diem Critical Care Codes: Direct Supervision and Reporting Guidelines 528 ||||||||||| APPENDIX IV. GLOBAL PER DIEM CRITICAL CARE CODES: DIRECT SUPERVISION AND REPORTING GUIDELINES IV. 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 as well as 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 residents or fellows are substitutes for the attending physician, who continues to remain fully in charge of these patients and directly supervises NNPs and residents or fellow physicians as well as other ancillary providers (eg, registered nurses, respira- tory therapists, nutritionists, social workers, physical therapists, occupational therapists), who all play important contributory roles in the care of these critical patients. Unlike the supervision for residents or 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 or 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 or fellow and NNP. When supervising residents or fellows, the attending physician will use this collective information as part of his or her own documenta- tion 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 or fellow’s findings, and discussed the plan of care with the resident or fellow to meet PATH guideline requirements. These rules allow the attending physician to use the resident or 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 postgradu- ate 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 services. If these NNPs are creden- tialed 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 employ- ees of the hospital or a medical group, reporting their services under their own NPI. It is important to emphasize again that the 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 ® 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 a 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 Coding_2021.indb 528 Coding_2021.indb 528 9/15/20 2:24 PM 9/15/20 2:24 PM
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