CMS Clarifies History and Physical on Day of Surgery

January 03, 2011

CMS has provided guidance that ambulatory surgical centers (ASCs) may perform a history and physical (H&P) on a patient the same day that patient is scheduled for surgery. The guidelines outlined in the letter are effective immediately.

The existing H&P requirement for ASCs, as written, had been causing confusion among state surveyors, who reportedly did not 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 three 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 operating room.
•"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."

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