Scott D. Duncan, M.D., M.H.A.

In the sweltering heat of the summer, medical students, residents, and fellows begin the next stage of their career journey. Recently graduated fellows become attending physicians with expanded responsibilities, including supervision of trainees. However, in the current healthcare environment, provider shortages, and reduced intensive care training requirements demand unique solutions for the provision of patient care.

One option to expand the workforce is to include APPs as employed qualified healthcare providers. Depending on the employment model, scope of practice, and state regulations, APPs may bill independently for services. In many academic institutions, both physicians and APPs are employed by provider organizations, separate from the hospital or university.

With the expansion of types of healthcare providers found in the NICU, a trainee may interact with an attending neonatologist and/or APP. In some academic institutions, an APP may supervise a trainee. These different training and employment models require an understanding supervision and correct billing practices.

Q 1: On the first day of service, a neonatologist in a teaching hospital attends a delivery with a pediatric resident. The infant is apneic at birth and requires PPV via face mask. The neonatologist instructed the resident to intubate the infant, which the resident accomplished under direct bedside supervision. The infant required additional PPV via an endotracheal tube, with subsequent recovery. The infant was subsequently transferred to the NICU.

Given the following codes, the correct coding for the neonatologist includes:

• 99465 – Delivery Room Resuscitation
• 31500 – Intubation

1. 99465, 31500
2. 99465
3. 31500
4. There was no billable service

Q 2: On the first day of service, a neonatologist in a teaching hospital attends a delivery with an APP, is employed by the care provider group, and is permitted to bill under state regulations. The infant is apneic at birth and requires PPV via face mask. The neonatologist instructs the APP to intubate the infant, which was accomplished by the APP. The infant required PPV via an endotracheal tube, with subsequent recovery. The infant was subsequently transferred to the NICU. Correct coding includes:

1. 99465 by the neonatologist, 31500 by the APP
2. 99465 by the APP
3. 99465,31500 by the neonatologist
4. There was no billable service

Q 3: On the first day of service, an APP in a teaching hospital attends a delivery with a pediatric resident. The infant is apneic at birth and requires PPV via face mask. The APP instructed the resident to intubate the infant, which the resident accomplished under direct bedside supervision. The infant required PPV via an endotracheal tube with subsequent recovery. The infant was subsequently transferred to the NICU. Correct coding for the APP includes:

1. 99465
2. 99465, 31500
3. 31500
4. There was no billable service

In each of the preceding scenarios, the correct answer is A. The focus of the questions is based on the supervision of trainees and the collaboration of care providers. In the first scenario, the neonatologist is supervising a trainee. Supervision and proper coding are dictated by Teaching Physicians, Interns & Resident Guidelines, published by the Centers for Medicare & Medicaid Services, often referred to as Physician at Teaching Hospitals or PATH guidelines. These guidelines can be found here: https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf.

When a teaching physician supervises a resident trainee, the physician must ensure proper documentation, demonstrating their involvement in the patient’s care. In this case, a delivery room note detailing the request for attendance at delivery, services provided, and disposition of the infant would be necessary. The medical record must be signed and dated with a legible signature or identity. Documentation may be:

• Dictated and transcribed
• Typed
• Handwritten and/or
• Computer-generated

The physician may place a ‘macro’ on the medical record; however, they must be placed anew daily. It is insufficient if a physician solely uses a macro for documentation purposes, without noting the physician’s presence during the provision of services and a description of the patient-specific services provided on that date, justifying the billing level for that encounter.

In the second scenario, an APP is not considered a trainee under PATH guidelines. Hence the attending neonatologist may code for the attendance at delivery and resuscitation but cannot bill for the intubation performed by the APP. In contrast, the APP could bill for the intubation but would defer the bill for the attendance of delivery to the neonatologist. Appropriate documentation would include a delivery room note by the attending physician denoting the request for attendance at delivery, a summary of the delivery and resuscitative efforts, an appropriate physical examination, and the disposition of the infant. The APP should document the procedure accordingly.

Similarly, according to PATH guidelines, an APP is not considered a supervising physician. As such, in the third scenario, the APP may bill for the resuscitation, as this would be considered their work. However, the APP cannot bill for the intubation performed by the resident. Appropriate documents should be included in the medical record by the APP for the attendance at delivery and the infant’s resuscitation, as well as a procedure note by the resident for the intubation of the infant.

As new models of providing patient care are developed and supervision of trainees shifts to include APPs, it is paramount to walk the correct PATHway!