What are the pre-surgical assessment requirements? We have an eye surgeon who wants to do an abbreviated pre-surgical assessment in their office but not have to do an update upon arrival the day of the procedure. Is this allowed?
What Are the Pre-Surgical Assessment Requirements?
Unfortunately, neither the CMS or TJC permit this scenario. In fact, there are really only 2 options:
Option 1: A full history and physical performed within 30 days of the planned procedure, followed by a brief examination, review of the H+P and an update note about any changes.
See TJC PC.01.02.03, EPs 4 and 5
Option 2: An abbreviated and documented assessment may be performed upon patient arrival for their procedure. This is described in your medical staff bylaws for certain low risk cases. You cannot perform an abbreviated and documented assessment prior to the patient’s arrival on the day of the procedure.
See TJC PC.01.02.03, EP 7
Ultimately, the surgeon needs to determine which option is most productive and efficient on the day of surgery. This may still be option 1, the one that hospitals have used for decades. The requirement to perform and document the abbreviated assessment after arrival for surgery is somewhat of a disincentive to option 2.
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Can we clarify if this is both inpatient and outpatient?
Ilyssa, you had asked if the abbreviated history and physical requirements applied to both inpatients and outpatients. The CMS rule only applies to outpatients. It is referenced in CMS A-0360 which is copied below.
“A-0360
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)
[The bylaws must:]
§482.22(c)(5) – Include a requirement that —
(iii) An assessment of the patient (in lieu of the requirements of paragraphs
(c)(5)(i) and (ii) of this section) be completed and documented after registration, but prior to surgery or a procedure requiring anesthesia services, when the patient is receiving specific outpatient surgical or procedural services and when the medical staff has chosen to develop and maintain a policy that identifies, in accordance with the requirements at paragraph (c)(5)(v) of this section, specific patients as not requiring a comprehensive medical history and physical examination, or any update to it, prior to specific outpatient surgical or procedural services. The assessment must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy”.