ASC Interpretive Guidelines Clarified

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  • January 3, 2011
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A comprehensive history and physical (H&P) may be performed on the same day as the surgical procedure in an ambulatory surgical center (ASC) “as long as the H&P is performed by qualified personnel, is comprehensive, and is placed in the patient’s ASC medical record prior to surgery,”  the Centers for Medicare & Medicaid Services (CMS) recently clarified in new guidance for state survey agency directors.
The Medicare agency decided to revise its interpretive guidelines for comprehensive medical H&P assessment after receiving “numerous questions” concerning the ASC H&P requirement.
Existing ASC H&P requirements state that each patient must have a comprehensive medical H&P assessment completed by a physician or other qualified practitioner “not more than 30 days before the date of the scheduled surgery.” State surveyors reportedly didn’t know if this meant that the assessment couldn’t be conducted on the same day as the surgery.
What this means, CMS clarifies in a letter to state surveyors, is “that the H&P assessment cannot be older than 30 days prior to the date of the surgical procedure. There is no prohibition against performing the H&P assessment on the same day as the surgical procedure, including being performed in the ASC,” provided the aforementioned conditions are met.
In the Dec. 17 letter, CMS also explains:
“If the patient H&P is conducted after admission to the ASC and on the date of the surgery, some elements of the pre-surgical assessment may be incorporated into the H&P.”
This does not, however, apply to the anesthetic/procedure risk assessment, which must be performed by a physician immediately before surgery and after the H&P. Nor is it acceptable to conduct the H&P after the patient has been prepped and brought into the operating or procedure room.
The guidelines are effective immediately.

Ambulatory Surgical Center CASCC

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  1. Stephanie says:

    Would we bill this out on an UB04 form?