Pre-surgical history and physical (H&P) rules continue to evolve. In December 2019, Medicare rules changed for procedures performed in an ASC. Read on for what you need to know.

Q. First the basics. What is an H&P, and why is it performed?

A. A comprehensive H&P exam is done to determine, before surgery, if anything in the patient’s overall condition would affect the conduct of the planned procedure or may even require cancellation of the procedure. It should address any chronic condition(s) — not just “surgical clearance”; this could be considered routine care, which is not covered.¹

Q. Who may perform the H&P prior to eye surgery?

A. According to CMS, “In the case of an ASC, the H&P is typically completed by the patient’s primary care practitioner rather than a member of the ASC’s medical staff.”² It may also be performed by a physician assistant (PA), a nurse practitioner (NP) or by the surgeon. Most ophthalmic surgeons prefer not to perform the H&P, because they do not feel competent to assess and treat medical conditions outside of their specialty and don’t want that liability.

Q. Where and when is the H&P done?

A. As a general rule, an H&P is not performed within the ASC due to time constraints, limitations of the state facility license, the desire to be reimbursed for this work and the presumption that an exam within the ASC is probably the required pre-anesthesia assessment by the anesthetist or the pre-surgical evaluation by the surgeon — neither is separately reimbursed.

Physicians rarely require a physical exam for surgeries performed in the office. For procedures performed in an ASC, Conditions for Coverage govern. Prior to December 2019, a comprehensive H&P was required 30 days prior to any surgery performed in an ASC. Now, each ASC is required to establish and implement a policy that identifies patients who require an H&P prior to surgery. Of course, the surgeon can still require an H&P for a particular patient, even if the ASC’s policy does not.

Requirements vary when the surgery is performed in a hospital outpatient department (HOPD), but most HOPDs require one within 30 days prior to surgery.

Q. May the H&P be performed on the same day the surgeon makes the decision for surgery?

A. Yes. Typically, someone other than the surgeon, and usually not another ophthalmologist, performs the H&P. So, even if both providers belong to the same group practice, they can be reimbursed on the same day because they belong to different specialties.³ For example, Medicare classifies an ophthalmologist as specialty 18, a PA as specialty 97 and an NP as specialty 50.

Q. Is an H&P part of the global surgery package if it is done by the surgeon?

A. When an H&P is performed by the surgeon within the global surgery period, including the day of surgery or the day before surgery, it is treated as part of the global surgery package.⁴ If the H&P is performed outside of the global surgery period, it might be reimbursed; however, the CPT panel of the American Medical Association has opined that it should not be. This question will likely be addressed more formally in the future.

Q. What is the typical level of service for an H&P?

A. The level of service of an evaluation and management (E/M) code varies with the amount of history, the number of exam elements and the degree of medical decision making. For short surgical procedures using minimal anesthesia on moderately healthy patients, the H&P is probably a level 2 or 3 E/M code; for long surgical procedures that require general anesthesia on elderly, fragile patients with serious chronic illnesses, the level of service may be higher. Note that eye codes are not applicable — this is not an eye exam.

Q. When billing an H&P, what diagnosis codes apply?

A. Use ICD-10 code Z01.81- (Encounter for preprocedural examination/preoperative examination/radiological and imaging examinations as part of preprocedural examination). List the ICD code(s) for the condition(s) that prompted surgery as secondary diagnoses. You may also include the condition(s) that prompted the preoperative medical evaluation in the first place.⁵

Q. What’s the difference between an H&P and a pre-surgical evaluation?

A. The required pre-surgical evaluation is performed on the date of surgery to assess any changes in the patient’s condition since the completion of the H&P. Additionally, it identifies and documents any allergies to drugs and biologicals.

Q. How is the H&P different from the anesthetist’s pre-anesthesia exam?

A. The pre-anesthesia physical exam is “to evaluate, based on the patient’s current condition, whether the risks associated with the anesthesia that will be administered and with the surgical procedure that will be performed fall within an acceptable range for a patient having that procedure in an ASC, given that the ASC does not provide services to patients requiring hospitalization”.⁶ It is a performed after the H&P and around the time of the pre-surgical evaluation, and is distinct from both. OM

REFERENCES

1. SSA. Sec 1862(a)(7) Routine Physical Checkups. https://www.ssa.gov/OP_Home/ssact/title18/1862.htm . Accessed Feb. 20, 2020.
2. CMS Manual System. Transmittal 71. Clarifications to Appendix L, Ambulatory Surgical Center Interpretive Guidelines –Comprehensive Medical History and Physical (H&P) Assessment and Anesthetic Risk and Evaluation. May 13, 2011. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R71SOMA.pdf . Accessed Feb. 20, 2020.
3. Medicare Claims Processing Manual, Chapter 12, §30.6.5. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Accessed Feb. 20, 2020.
4. Medicare Claims Processing Manual, Chapter 12, §40. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Accessed Feb. 20, 2020.
5. Medicare Carriers Manual, Transmittal 1719. August 31, 2001. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1719B3.pdf . Accessed Feb. 20, 2020.
6. CMS Manual System. Transmittal 71. May 13, 2011. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R71SOMA.pdf . Accessed Feb. 20, 2020.

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .