Cutting through the confusion: Clarifying history & physical and update notes
One of the most confusing areas for outpatient surgery providers undergoing Medicare surveys is the history and physical (H&P), including update notes.
While the rules from the Centers for Medicare and Medicaid Services (CMS) don' t specify what constitutes a "comprehensive" history & physical (H&P) or which elements of the pre-surgical assessments may be incorporated into the H&P, the regulations provide that an update note does not act as an H&P and doesn' t make an H&P older than 30 days current.
"The update examination for any changes in the patient' s condition since the H&P was performed is more abbreviated than that of a comprehensive H&P," says W. Jan Allison, RN, CHSP, director of accreditation and survey readiness, Clinical Services Department, , Birmingham, AL. "In other words, when an H&P is older than 30 days, the H&P must be redone and is not eligible to be updated since the update assessment is not comprehensive enough to make the H&P current."
Allison cites the CMS regulations as her source. "In addition, it is the expectation during survey from the surveyors," she says. "It has been cited as a deficiency during surveys when the H&P has been older than 30 days, in spite of the H&P containing an update note indicating assessment of the patient on the day of service."
Regardless of the type of surgical procedure, a "comprehensive" medical H&P assessment must be completed by the physician not more than 30 days before the date of surgery, according to 416.52(a)(1), Allison says. "The standard set forth in 416.52(a)(2) additionally requires that upon admission, each patient must have a pre-surgical assessment completed by a physician or other qualified practitioner and that, at a minimum, there must be an updated medical record entry documenting an examination for any changes in the patient' s condition since completion of the most recently documented history and physical assessment," she says.
A memo issued by CMS in December 2010 (S&C-11-06-ASC) clarifies that a comprehensive H&P may be performed on the same day as the surgery, Allison says, "and in the event it is, some elements of the required pre-surgical assessments may be incorporated into the H&P." (That memo can be accessed at http://go.cms.gov/PGo60B.)
The Joint Commission also requires accredited facilities to have an H&P in the record before the procedure (RC.02.01.03 EP 3 for hospitals; PC.03.01.03 EP5 and PC.03.01.03 EP6 for ambulatory and office-based organizations). The Accreditation Association for Ambulatory Health Care (AAAHC) requires organizations to have it completed within 30 days prior to scheduled surgery, or according to local and state requirements (whichever is stricter). The exact language can be found in Standard 10.I.D. (For guidance on what items constitute a comprehensive H&P, look to the CMS "Evaluation and Management Services Guide" at http://go.cms.gov/KrBG4l. Also see story, below.)
Medicare also requires a pre-procedure anesthesia assessment.
Your independent practitioners might be completing the H&P update but not getting credit for it, warns Jennifer Cowel, RN, MHSA, vice president of Glendale, AZ-based Patton Healthcare Consulting, which offers regulatory compliance and accreditation readiness consulting. Cowel is a former surveyor for The Joint Commission and former director of service operations in accreditation in the central office. Cowel spoke earlier this year at a webinar sponsored by AHC Media, publisher of Same-Day Surgery, about "The Surveyors are Here, Now What? Successful Strategies for Your Next TJC Survey." (For ordering information, see Resource at end of this article.)
"The H&P update is something you expect your licensed independent practitioners to do, you expect them to document it, but a lot of organizations are still expecting the physician to check a little box," Cowel says. "[W]hat we see on-site is that the physician will sign it, date it, time it, do it, and get no credit because a box is not checked."
Use forms with easier comliance
Look over your forms to see which ones still mandate checkboxes, and consider implementing a form that offers easier compliance, she says. "You have canned language that says, ' I have examined the patient. I have reviewed the findings, the history & physical, and there are no changes other than noted below,' ... or 'there are no changes,' " Cowel says.
Have the practitioner sign, date, and time it, she says. "By virtue of their signature, they are attesting to the fact that this sentence up here has occurred," Cowel says. "No checkbox is necessary."
Resource
The webinar "The Surveyors are Here, Now What? Successful Strategies for Your Next TJC Survey," offers an up-to-date view of what to expect when surveyors come to your facility and learn how to be prepared when they do. If offers success strategies for a smooth and successful survey. The price for the webinar is $350. To order, go to http://bit.ly/RNe7Ga.
What is included in the history & physical A comprehensive history & physical (H&P) includes the following items: a chief complaint; an extended history of present illness; a review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; and complete past, family and/or social history, according to Jan Allison, RN, CHSP, director of accreditation and survey readiness, Clinical Services Department, Surgical Care Affiliates, Birmingham, AL. Include these details, as pulled by Allison from the Medicare "Evaluation and Management Services Guide" at http://go.cms.gov/KrBG4l: • Chief complaint: a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. • History of present illness (HPI): a chronological description of the development of the patient' s present illness from the first sign and/or symptom (onset) or from the previous encounter to the present. HPI elements are: – location; – quality; – severity; – duration; – timing; – context; – modifying factors; – associated signs and symptoms. • Complete review of systems (ROS): an inventory of body systems obtained by asking questions to identify signs and/or symptoms that the patient might be experiencing or has experienced. It include a complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) organ systems. "Those systems with positive or pertinent negative responses must be individually documented, Allison says." "For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented." • Complete past, family, and/or social history (PFSH): PFSH consists of a review of three areas: – Past history including experiences with illnesses, operations, injuries, and treatments. "Here you list patient' s useful, ongoing medical problems and a list of surgeries," Allison says. If something is recent or pertinent to the current (present) illness, more detail should be added, she says. "Include dates and time of pertinent items, if they are pertinent to the current complaint," Allison says. "Also, chronic problems should be addressed as to whether or not they are well-controlled, uncontrolled, etc., especially, if they pertain to the current illness." – Family history, including a review of medical events, diseases, and hereditary conditions that might place the patient at risk. – Social history including an age-appropriate review of past and current activities. A complete PFSH is a review of two or all three of the areas, depending on the category of the evaluation and management (E/M) service. |
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