“If the H&P is performed on the day of the surgical procedure in the ASC, some but not all elements of the pre-surgical assessment may be incorporated into the H&P. However, the assessment of the patient’s risk for the procedure and anesthesia required under 416.42(a)(1) must still be conducted separately by a physician and immediately prior to surgery”.
The article also says:
“It is not acceptable to conduct the H&P after the patient has been prepped and brought into the operating or procedure room, since the purpose of the H&P is to determine before the surgery whether there is anything in the patient’s overall condition that would affect the conduct of the planned procedure or which may even require cancellation of the procedure … The H&P should specifically indicate that the patient is cleared for surgery in an ambulatory setting.”
Optimally, your facility’s current process should be reflective of what is stated above. Understanding the reality of daily operations, the implementation of the above may not seem practical in your setting especially if the attending GI physician is the same physician providing direct supervision of RN IV conscious/moderate sedation and is therefore responsible for the patient’s sedation as well. However, deviation from any of these CMS standards would subject your facility to potential risk of non-compliance based on a surveyor’s interpretation. So, based on my literal interpretation of the above, it would still mean the following should occur:
– The patient’s H&P would be performed in the pre-op area.
– A separate documented assessment would be done to demonstrate evidence that the patient was examined immediately before surgery (or procedure in your case) to evaluate the risk of anesthesia and of the procedure to be performed.
– Both documents are placed in the patient’s medical record prior to the procedure.
My other suggestion is to consider calling your State Department of Health and having a discussion with their supervisor of Medicare surveyors for further clarification from their perspective, obtain it in writing if possible and keep it on file in your center.
Learn more about Health Inventures.
Read more from the leadership of Health Inventures:
– How to Know When to Expand a Surgery Center: Q&A With Dawn Q. McLane of Health Inventures
