CMS SOM App. A, Tag A-0360

§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.

Interpretive Guidelines §482.22(c)(5)(iii)

In lieu of the medical staff bylaws for history and physical requirements at §482.22(c)(5)(i) and

(ii), a hospital and its medical staff are free to exercise their clinical judgment in determining

whether to implement a policy for identifying, in accordance with §482.55(c)(5)(v), specific

patients as not requiring a comprehensive history and physical or any update prior to specific

outpatient surgery or a procedure requiring anesthesia. The option permits a pre-surgical

assessment for these patients when appropriate.

The assessment must be completed and documented in the medical record 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, after registration, but prior

to surgery or a procedure requiring anesthesia services.

Survey Procedure §482.22(c)(5)(iii)

• If the medical staff has opted to require a pre-surgical assessment for certain patients,

review the written policy for identifying specific patients as not requiring a comprehensive

history and physical prior to specific outpatient and surgical procedures.

• Review a sample of medical records of patients who had a pre-surgical assessment prior to

outpatient surgeries or procedures for documentation that the assessments were completed

and documented in the medical record 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, after registration, but prior to surgery or a

procedure requiring anesthesia services.