Recent Conditions of Participation ("CoP") Changes to History and Physical ("H&P") Requirements

(PYA Alert dated January 30, 2007)

The final CMS Conditions of Participation ("CoP") regulation published in the November 27 Federal Register offers increased flexibility for an often challenging quality monitor, timeliness of history and physical ("H&P") reports.

Prior to the final regulation, the proposed regulation had required completion of an H&P seven days prior to admission or within 48 hours following admission. The CoP final rule offers greater physician flexibility, with a time frame of 30 days prior to admission and 24 hours following admission. If an H&P is completed prior to actual hospital admission, it must be updated within 24 hours or prior to performing surgery. Of note, these requirements apply to both inpatients and outpatients, and, certain identified nonphysician practitioners may also complete the H&P.

Related to H&P’s performed by nonphysician practitioners, the CoP largely steers clear of this frequently debated issue. CMS indicates in the final regulation that a facility’s medical staff may designate, in accordance with state law, those nonphysician practitioners who may perform H&P’s. If state law stipulates this responsibility as within the scope of a practitioner’s licensure, nonphysician practitioners may perform H&P’s, provided that the facility has appropriately allowed for this (e.g., outlined in medical staff and/or hospital governing documents such as bylaws, rules and regulations, etc.).

Has this information been helpful? It’s hard to keep up with so many changes in the healthcare industry. PYA's credentialed health information professionals are prepared to assist with your facility’s HIM compliance needs including operations, coding and DRG validation, documentation improvement, business strategy, education, and many others. Please contact Carol Eyer at (800) 270-9629 for more information.

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