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heathercompton1988@yahoo.com

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There is discussion in my office as to how to interpret the CMS rules for billing a comprehensive history and physical within 30 days of a procedure performed at an Ambulatory Surgical Center (to clear the patient for the procedure). I have attached the document that we are attempting to interpret. Some believe that a comprehensive H&P does not necessarily mean that you have to meet the requirements of a 99215, some believe that a 99214 is still a comprehensive exam even if that is not the specific code description. Others believe that all components of a 99215 must be met, so if a physician sees the patient (within the 30 days) and only billed a 99214, then another qualified practitioner must evaluate the patient prior and meet the requirements of a 99215.

Any insight is very appreciated!
 

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  • CMS ASC HP rules.pdf
    264.9 KB · Views: 8
The regulation you're referencing is "Guidance for Surveyors" and is not really a rule pertinent to coding and billing. They've listed the comprehensive H&P as a required document that the facility must have on record but there is no mention of any requirements that it conform to the E&M documentation guidelines and I don't believe it would be audited in this manner. In my experience with facility surveys, this H&P would be one item on a long checklist of items that they would randomly review in the course of the survey to confirm that it is included in the chart - I can almost guarantee that they would not count elements of a history and exam in the notes to see what level it comes out to if it was coded. In almost all cases, surveyors are not trained coders and that is not really their role. The facility where I worked most recently (which was a hospital, but has a similar requirement) would have the surgeon sign an attestation as part of the admission documents stating that he or she had performed the required H&P, and would attach a copy of the physician's most recent visit note. As far as I know, this was always sufficient and did not result in any citations of deficiencies during surveys. If you're really concerned though, you might want to contact your state's ASC credentialing/licensing organization to get their input and see if they have published any more specific guidance as to what they look for when they conduct their reviews.
 
Comprehensive vs Comprehensive

Often the term "comprehensive" used in regulations does not equal "comprehensive" as understood in E/M auditing language. A comprehensive H&P simply means a complete history and physical related to the patient in preparation for surgery. From there, the documentation would need to be reviewed to ensure it meets the required Evaluation & Management elements to support a code level. Simply using a term in a different context does not ensure direct translation.

See Merriam-Webster's definition: https://www.merriam-webster.com/dictionary/comprehensive
 
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