News Alert: CMS Proposes to Ease H&P Requirements for Hospital and ASC Surgeries

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Original story posted on: September 17, 2018

CMS says proposal will save U.S. healthcare facilities $1.12 billion annually.

In a surprise move, the Centers for Medicare & Medicaid Services (CMS) has released proposed rule CMS-3346-P to, in the words of its title, “Promote Program Efficiency, Transparency, and Burden Reduction.”

The proposed rule contains regulation changes applicable to acute-care hospitals, ambulatory surgery centers (ASCs), hospices, home health agencies, skilled nursing facilities (SNFs), religious nonmedical healthcare institutions, and more.

Of interest to RACmonitor readers is a significant proposal to reduce the documentation requirements for pre-operative history and physical examinations (H&Ps) in both hospitals and ASCs. CMS is proposing to remove the requirement that all patients have a comprehensive H&P prior to undergoing a surgical procedure. Citing the literature demonstrating a lack of utility to preoperative testing in patients undergoing cataract surgery, the most common surgery performed on Medicare beneficiaries in ASCs, and the “inherently arbitrary and burdensome” requirement for the H&P to be done within 30 days, CMS is proposing to allow hospitals and ASCs to develop their own policies.

In regard to ASCs, CMS states that, if adopted, it would “defer to the facility’s established policies for pre-surgical medical histories and physical examinations (including any associated testing) and the operating physician’s clinical judgment, to ensure patients receive the appropriate pre-surgical assessments that are tailored for the patient and the type of surgery being performed.”

“We propose to require each ASC to establish and implement a policy that identifies patients who require an H&P prior to surgery ... (and)we propose that the policy would be required to consider the age of patients, their diagnoses, the type and number of surgeries that are scheduled to be performed at one time, all known comorbidities, and the planned level of anesthesia for the surgery to be performed,” the language continues. “ASCs would not be limited to these factors and would be permitted to include others to meet the needs of their patient populations. Furthermore, we propose that each ASC’s policy would be required to follow nationally recognized standards of practice and guidelines, as well as applicable state and local health and safety laws.”

Because hospitals are regulated by a separate set of conditions of participation and the current requirements specify that all patients undergoing surgery with anesthesia have an H&P within 30 days with an update within 24 hours, CMS has proposed to add an addendum to regulations allowing hospitals to adopt a policy that would allow certain specified surgeries to be performed without a comprehensive H&P, replacing it with a pre-surgical assessment. CMS has specified that “this proposed requirement would only apply in those instances 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 … 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.”

As a general internist who was frequently called upon to perform pre-operative H&Ps on my Medicare patients undergoing cataract surgery, I am delighted that CMS recognizes the lack of utility and waste of resources that this requirement created. If finalized, hospitals and ASCs will need to develop careful procedures to ensure that patients who are considered to be of higher risk do in fact get identified prior to the day of surgery and are able to have a proper, comprehensive pre-operative evaluation – and that there is no undue pressure on ancillary staff to allow a patient to proceed to the operating room if there is a question of safety or appropriateness.

The proposals specific to the other providers mentioned above include changes to discharge planning at religious nonmedical healthcare institutions, fewer required staff at hospice agencies, lessened staff orientation at SNFs, allowance of system-wide infection control programs for multi-hospital systems instead of individual programs at each hospital, giving home health agencies four business days to provide a patient with a copy of their clinical record, and more.

You can read the proposed rule online at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-19599.pdf

Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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