Intensive care management services in Medicare 011-42060090

Intensive care is extensive and continuous care and treatment provided for an acutely ill patient, usually in a specially designated section (intensive care unit) of a hospital.

Intensive care management items are divided into 2 categories.

• Group T1 - Subgroup 9, procedures associated with intensive care and cardiopulmonary support, and
• Group T1 -Subgroup 10, management and procedures undertaken in an intensive care unit

Medicare benefits are only payable for management and procedures in intensive care covered by items 13870, 13873, 13876, 13882, 13885 and 13888 where the service is provided by a specialist or consultant physician who is immediately available and exclusively rostered for intensive care.

A general intensive care unit means a separate hospital area that meets all of the following:

• is equipped and staffed so as to be capable of providing to a patient:
• mechanical ventilation for a period of several days
• invasive cardiovascular monitoring
• is supported by all of the following:
• at least one specialist or consultant physician in the specialty of intensive care who is immediately available and exclusively rostered to the ICU during normal working hours
• a registered medical practitioner who is present in the hospital and immediately available to the unit at all times
• a registered nurse for at least 18 hours in each day
• has defined admission and discharge policies

A neonatal intensive care unit means a separate hospital area that meets all of the following:

• is equipped and staffed so as to be capable of providing to a patient, being a newborn child all of the following:
• mechanical ventilation for a period of several days
• invasive cardiovascular monitoring
• is supported by all of the following:
• at least one consultant physician in the specialty of paediatric medicine, appointed to manage the unit, and who is immediately available and exclusively rostered to the ICU during normal working hours
• a registered medical practitioner who is present in the hospital and immediately available to the unit at all times
• a registered nurse for at least 18 hours in each day
• has defined admission and discharge policies

Note: 'Immediately available' means that the intensivist must be predominantly present in the ICU during normal working hours. Reasonable absences from the ICU would be acceptable to attend conferences, meetings and other commitments which might involve absences of up to 2 hours during the working day.

'Exclusively rostered' means that the specialist’s sole clinical commitment is to intensive care associated activities and is not involved in any other duties that may preclude immediate availability to intensive care if required.

Given that an intensive care unit must have defined admission and discharge policies, the following guidelines should be followed in relation to admission criteria for intensive care benefits:

• Benefits are payable for admissions to an intensive care unit following surgery only where clear clinical justification for post-operative intensive care exists.
• Benefits are payable for the admission of babies who meet at least one of the following criteria:
• all babies weighing less than 1000 grams
• all babies with an endotracheal tube, and for the 24 hours following endotracheal tube removal
• all babies requiring Constant Positive Airway Pressure (CPAP) for acute respiratory instability
• all babies requiring more than 40% oxygen for more than 4 hours
• all babies requiring an arterial line for blood gas and pressure monitoring
• all babies having frequent seizures
• Benefits are not payable for intensive care services under items 13870-13888 for babies who are ready for discharge from the neonatal intensive care unit, but are physically retained within the unit for other reasons.
• Benefits are not payable for intensive care services under items 13870-13888 for babies not meeting the above admission criteria who, for whatever other reasons, are physically located within the neonatal intensive care unit.

Note: the reference to a day relates to a calendar day not a 24 hour period. A management fee should not be raised for periods when patients are in an ICU for short periods of time, that is, less than two hours.

Given that most services within the Schedule for ICU services are structured to be itemised on a calendar day basis, where it is necessary to transfer a patient from one ICU to another, the billing of the patient is a matter for arrangement between the ICUs involved.

For services rendered by other practitioners, the following rules apply:

• benefits are payable for an attendance by another specialist/consultant physician who is not managing the patient but who has been asked to attend the patient
• where appropriate, accounts should be endorsed to the effect that the consultation was not part of the patient's intensive care management in order to identify which consultations should attract benefits in addition to the intensive care items

For more information regarding Medicare benefits for management and procedures in Intensive Care Unit, refer to the Medicare Benefits Schedule Therapeutic Procedures Category 3 explanatory notes.