Wiki Clinic procedure H&P

TnRushFan

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Good morning folks,
Several administrative office folks I know are having a discussion about clinic based procedures and the requirements of the H&P. I'm hoping to glean a few authoritative opinions/references.

Example:
Imagine, you have a 2cm lump on your arm that you do not like.
  1. You go to General Surgery Procedure clinic run by our PAs who meet you in-person for the first, last, and only time.
  2. Our PAs do a comprehensive history and physical.
  3. They agree you have a 2cm pea sized lump, and ask you if you want the lump removed
  4. IN CLINIC, they sterily prep, anesthetize your skin, and cut out the lump (goes to path).
  5. You go home from clinic.

The main question is,
Does the H&P have to be written within 30 days and updated within 24 hours [like for a regular surgery requiring anesthesia] or can it just be within 30 days?
Does it need to be a stand alone document or can it be part of the consult record?
Can the H&P be on the procedure note?

As a Surgery Coder my understanding may be a little removed from a Clinic Coder.
My position is, it should be written within 30 days [since no anes required] and reviewed, comment entered on progress note for clinic procedure...but it needs to be stand alone document. I can find no CMS or JACHO reference to substantiate my position...will be glad for any input.

Thanks in advance...
 
Assuming your clinic is part of a hospital or other facility and not a free-standing practice, it's my understanding that your facility's leadership and/or medical director, in consultation with their legal department, should have an established written policy with guidelines stating under what circumstances an H&P is required. It shouldn't be up to an individual coder to determine this.

In the hospital system where I worked for a number of years, a separate comprehensive H&P was never required for minor procedures done in the clinic under local or no anesthesia - only for procedures that required a trip to the OR or an inpatient admission. However, there may be regulations that could vary from state to state depending on where your providers are practicing.

Perhaps someone on the forum has more knowledge of this than I do, but this question falls more along the lines of hospital management and outside the normal scope of coding responsibility.
 
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