History & Physical Requirement Changes – Ambulatory Surgery Centers

CMS’s recently announced adoption of the final rule that will make changes to several regulatory requirements that affect hospitals, critical access hospitals and/or Ambulatory Surgery Centers. These changes will be phased in over the next two years. The first change removes the current requirements found at 416.52(a) for a H&P within 30 days of the procedures in Ambulatory Surgery Centers. The H&P requirement has been replaced with requirements that will (1) defer to the ASC’s policy regarding available patient medical information prior to surgery and (2) the clinical judgement of the physician performing the procedure/operation. These two components should result in ensuring the appropriate pre-surgical assessments are tailored to the patient and the type of surgery performed.

The CMS requirements will continue to require the physician performing the procedure to document any pre-existing medical conditions and appropriate test results, in the medical record, before, during and after the surgical procedure.

While the information for the pre-surgical assessment of the patient may change, the requirement that all pre-surgical assessments include documentation of allergies to drugs and biologicals be contained within the medical record remains intact. The medical history and physical, if completed or other relevant information that is being used to replace the H&P must also be placed in the patient’s medical record prior to the surgical procedure.

Please remember, this change is only effective in those organizations that are licensed as Ambulatory Surgery Centers.

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