Topic: CMS discusses documentation for H&Ps during recent ODF call
HIM Connection, January 22, 2008
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CMS hosted a Hospital Open Door Forum (ODF) call on November 8, 2007, during which it discussed several inpatient and outpatient changes. During the call, CMS clarified that providers must document history and physicals (H&P) no more than 30 days before or 24 hours after admission or registration for surgery that requires anesthesia.
Providers must also complete an update that includes any changes to the patient's condition. This update must be completed and documented within 24 hours after admission or registration but prior to surgery that requires anesthesia services. A CMS representative stated that only a physician, surgeon, or other qualified licensed individual may perform the H&P.
Individuals who are qualified to administer anesthesia must complete and document preanesthesia evaluations within 48 hours prior to surgery for a procedure that requires anesthesia. A qualified individual must also document a postanesthesia evaluation no later than 48 hours after the surgery.
Editor's note: This tip is adapted from a January 2008 article in Briefings on Coding Compliance Strategies. For more information, click here.
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