TnRushFan
Networker
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.
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...
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.
- You go to General Surgery Procedure clinic run by our PAs who meet you in-person for the first, last, and only time.
- Our PAs do a comprehensive history and physical.
- They agree you have a 2cm pea sized lump, and ask you if you want the lump removed
- IN CLINIC, they sterily prep, anesthetize your skin, and cut out the lump (goes to path).
- 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...