Requirements for Comprehensive Medical History and Physical Assessment
Proposed Rule: CMS proposed to “remove the current requirements at §416.52(a) and replace them with requirements that defer, to a certain extent, to the ASC policy and operating physician’s clinical judgment to ensure that patients receive the appropriate pre-surgical assessments tailored to the patient and the type of surgery being performed.” The operating physician would still have to document any pre-existing medical conditions and appropriate test results in the medical record, which would have to be considered before, during and after surgery. In addition, all pre-surgical assessments would still be required to include documentation regarding any allergies to drugs and biologicals. The H&P, if completed, would be placed in the patient’s medical record prior to the surgical procedure.
Final Rule: CMS finalized the proposal to revise the requirement at § 416.47(b)(2) to state “Significant medical history and results of physical examination, as applicable.” They finalized the proposal to eliminate the requirement at § 416.52(a) for each patient to have a medical history and physical assessment (H&P) completed by a physician not more than 30 days before the scheduled surgery and replaced it with the requirement for ASCs to develop and maintain a policy that identifies those patients who require an H&P prior to surgery.
The facility’s policy must include the timeframe for the H&P to be completed prior to surgery. The policy must also address, but not be limited to, the following factors: patient age, diagnosis, the type and number of procedures scheduled to be performed on the same surgery date, known comorbidities and the planned anesthesia level. Upon admission, each patient must have a pre-surgical assessment completed by a physician or other qualified practitioner, in accordance with applicable state health and safety laws, who will be performing the surgery.
CMS also revised § 416.52(a)(1)(iii) to clarify that the ASC policy must be based on nationally recognized standards of practice and guidelines, and applicable state and local health and safety laws.