Dawn Q. McLane, RN, MSA, CASC, CNOR, regional vice president of operations, and Cindy A. King RN, CPHQ, director of clinical, quality and compliance, for Health Inventures share their interpretation of the recently issued guidance clarification from CMS for ambulatory surgery centers concerning ASCs performing a patient's history and physical (H&P) on the same day of surgery.
Dawn Q McLane: Many surveyors felt the interpretive guidelines indicated that the H&P was to be performed prior to the date of surgery and was to be updated on the day of survey. Further that the surgeon's H&P is distinct from the anesthesia provider's anesthesia assessment. One reason for this is that it assists the center in determining if the patient meets the admission criteria and is an appropriate patient for the ASC environment. Now Medicare says that the H&P can be performed on the day of the procedure. It helps some specialties like GI and Pain, but may be problematic for the more complex cases or patients who have a more complex medical history and co-morbidities and could lead to more same-day cancellations.
Cindy A. King: In addition to the above, there still seems to be some remaining questions regarding which elements of the H&P assessment that can be combined with some, but not all of the elements of the same day pre-surgical assessment. This pertains to an H&P that is conducted prior to the date of surgery; a pre-surgical assessment must be completed by a physician or other qualified practitioner in accordance with state law on the date of surgery that includes at a minimum, documentation of an exam for changes in the patient's condition since completion of the most recent H&P including allergies to drugs and biologicals. The physician or qualified licensed practitioner uses his/her clinical judgment based upon their assessment of the patient's condition, co-morbidities, etc., as it correlates to the patient's scheduled procedure in order to decide the extent of this update assessment and corresponding documentation.
It is important to note that the assessment of the patient's procedure/anesthetic risk must be conducted separately from the H&P and separate from the other elements of the pre-surgical assessment that update the H&P.
As a final note, the documented H&P must be placed in the patient's medical record prior to the surgery/procedure.
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