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CMS: History & Physical Can Be Performed on Day of Surgery

Regulator responds to confusion over H&P rule for ASCs.

Published: December 22, 2010

Ambulatory surgery centers may perform a history and physical on a patient the same day that patient is scheduled for surgery, the Centers for Medicare and Medicaid Services has clarified in new guidance for state surveyors.

The existing H&P requirement for ASCs, as written, had been causing confusion among state surveyors, who reportedly didn't know whether the requirement that H&Ps be performed "not more than 30 days before the date of the scheduled surgery" allowed the assessments to be conducted on the actual day of surgery. The ASC Association says it brought this concern to the attention of CMS, which responded by issuing a letter to state survey agencies late last week clarifying the requirement. The letter clarifies 3 major points:

  • "The comprehensive H&P may be performed on the same day as the surgical procedure, and may be performed in the ASC." However, the H&P must be performed before the patient is prepped and brought into the OR.

  • "If the H&P is performed on the day of the surgical procedure in the ASC, the H&P assessment may be combined with some, but not all, of the elements of the pre-surgical assessments." Specifically, it cannot be combined with the anesthesia/procedure risk assessment, which must be performed after the H&P by a physician.

  • "A comprehensive medical H&P assessment is required regardless of the type of surgical procedure."

    The guidelines outlined in the letter are effective immediately. Read the full letter here.

    Irene Tsikitas

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