CMS SOM App. A, Tag A-0362

§482.22(c)(5) - [Include a requirement that --]

• The medical staff, if it chooses to develop and maintain a policy for the

identification of specific patients to whom the assessment requirements in

paragraph (c)(5)(iii) of this section would apply, must demonstrate evidence

that the policy applies only to those patients receiving specific outpatient

surgical or procedural services as well as evidence that the policy is based on:

•

(A) Patient age, diagnoses, the type and number of surgeries and procedures

scheduled to be performed, comorbidities, and the level of anesthesia

required for the surgery or procedure.

(B) Nationally recognized guidelines and standards of practice for assessment of

specific types of patients prior to specific outpatient surgeries and

procedures.

(C) Applicable state and local health and safety laws.

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

When the hospital and medical staff chooses to exercise the flexibility to perform a pre-surgical

assessment, in lieu of the comprehensive history and physical (H&P) and updates, they are

required to develop and maintain a written policy, approved by the governing body, that

specifies those outpatients and surgeries and procedures for which this optional assessment

would apply.

Policies must address certain patient characteristics that may necessitate the need for

examination and testing prior to surgery. These factors include but are not limited to, the

following:

• patient age (considering the need for H&P based on pediatric, adult, or geriatric age

differences),

• diagnosis,

• the type and number of procedures scheduled to be performed on the same surgery date,

• known comorbidities (e.g. cardiac or pulmonary disease), and

• planned anesthesia level (e.g. minimal sedation vs general anesthesia).

Additionally, the written policy requires the consideration of and based on:

• national standards and guidelines of practice for the assessment of specific types of

patients prior to specific outpatient surgeries and procedures, and

• any applicable State and local health and safety laws.

Survey Procedure §482.22(c)(5)(v)

• Review a sample of medical records of patients receiving outpatient surgery to determine

whether evidence exists that patients who did not receive a comprehensive history and

physical prior to receiving outpatient surgeries and procedures met the criteria outlined

in the medical staff policy.

• Review the hospital’s policies and procedures regarding H&Ps to determine if they are

consistent with the regulatory requirement.

• Is there documentation that the hospital has developed the H&P policies based on

nationally recognized standards of practice and guidelines, and any applicable State and

local health and safety laws?