History and physical (H&P)

The history and physical is the foundational documentation record for any orthopedic surgical or procedural encounter. The history component captures the chief complaint, history of present illness, past medical and surgical history, medications, allergies, family history, social history, and a review of systems. The physical examination component records pertinent musculoskeletal and systemic findings, including range of motion, neurovascular status, strength, and any co-morbid conditions relevant to anesthesia or surgical risk.

For ambulatory surgery centers (ASCs), CMS regulations under 42 CFR 416.52(a)(1) have historically required a comprehensive H&P completed no more than 30 days before the scheduled procedure. If performed on the same day as surgery at the ASC, the anesthesia and procedural risk assessment must be conducted as a separate, discrete element rather than embedded in the H&P update. When a previously completed H&P is used, the treating physician must review it, confirm it is still current and accurate, and document an update note before the procedure begins.

For Evaluation and Management (E/M) coding purposes, CMS and AMA significantly revised the rules effective January 1, 2021. History and physical examination components no longer drive E/M level selection for office and outpatient visits; Medical Decision-Making (MDM) or total time on the date of the encounter now determines the CPT code billed. Nevertheless, the H&P remains clinically and regulatorily essential as the documentation foundation for establishing medical necessity, supporting prior authorizations, and satisfying accreditation requirements under The Joint Commission and CMS Conditions of Participation.

An incomplete or missing H&P is one of the most direct triggers for claim denial, audit findings, and surgical delay. Payers rely on H&P documentation to confirm medical necessity; if the record does not demonstrate why the procedure was clinically indicated, the claim is vulnerable regardless of how accurately the CPT and ICD-10 codes are selected. Under Joint Commission standards, a privileged physician must review and attest to any H&P not personally performed, and a medical student's H&P carries no independent legal standing. In the ASC setting, a stale H&P—one older than 30 days at the time of surgery—requires a compliant update note; failure to document that update exposes the facility to a failed survey finding. For prior authorizations on MRIs, injections, and complex surgeries, payers increasingly demand the H&P alongside imaging reports before granting approval; a missing or vague H&P forces costly resubmissions and delays care.