Scheduling Resources

History & Physical Requirement

A History and Physical (H&P) exam must be completed within 30 days of the scheduled surgery and preferably prior to the Pre-Anesthesia Testing (PAT) visit. All H&P forms must be typed, dictated or entered into WakeMed Epic, signed, dated and timed by the licensed independent provider (LIP).

Patient Status

In order to schedule/pre-register a patient for surgery or procedure, a case request that indicates the expected patient status is required.  This applies to all patients who are not in WakeMed acute care facility at the time of scheduling.

Medicare has established a list of procedures that can only be performed on an inpatient basis. This list is commonly referred to as Addendum E. If a procedure is on Addendum E, and the patient is Medicare, then Medicare will not cover the procedure unless the patient status is inpatient. With the exception of Addendum E procedures, it is okay for the status order to change after scheduling the patient if it is determined that another status would be more appropriate. A change of status always requires a physician order.

• CMS Addendum E Inpatient Only List 

Surgery Admit Inpatient

OPA – Outpatient to be admitted

• Medicare – surgery planned IS listed on Addendum E (CMS inpatient only) list or expected 2 or more days length of stay
• Medicaid – surgery planned IS listed on the InterQual “inpatient only “ list and MD intent is inpatient
• Other payers as authorized

Outpatient

OPB – Outpatient to a bed 

• Medicare, Medicaid, Self pay, most commercial insurers
• Patient is coming in as an outpatient for OP surgery/procedure and possible overnight stay planned
• Placed in a bed for a short period of time
• For Medicare/Medicaid – surgery to be performed is NOT on the “inpatient only” list

OBS - Observation 

• NEVER use for Medicare/Medicaid planned surgery/procedure
• Plan is to be placed in a bed for an extended period of observation services
• Used by a limited number of Commercial payers
• May require an overnight stay

OPH – Outpatient Home 

• Patient is coming in as an outpatient for planned OP surgery/procedure and plan is to return home.

WakeMed Surgery Scheduling and Pre-Registration Process

In order to schedule/pre-register a patient for surgery or procedure, a physician order that indicates the expected patient status will be required. This applies to all patients who are not in a WakeMed acute care facility at the time of scheduling.

A patient status order indicates one of four categories indicating that after surgery the patient is expected to:

• Return home (OPH); OR
• Be placed in a bed for a short period of time (OPB); OR
• Be placed in a bed for an extended period of observation services (OBS); OR
• Be an inpatient (OPA or Acute Inpatient).

Inpatient status generally indicates that the patient is expected to spend at least one night in the hospital (Status=OPA or Acute Inpatient). To clarify, patients placed in a bed for a short period of time (Status=OPB) or for extended observation services (Status=OBS) may spend the night in the hospital even though they are not classified as an inpatient.

Medicare has established a list of procedures that can only be performed on an inpatient basis. This list is commonly referred to as Addendum E. If a procedure is on Addendum E, and the patient is Medicare, then Medicare will not cover the procedure unless the patient status is inpatient. With the exception of Addendum E procedures, it is okay for the status order to change after scheduling the patient if it is determined that another status would be more appropriate. A change of status always requires a physician order.

• CMS Addendum E Inpatient Only List

If the patient you are scheduling is not currently in a WakeMed acute care facility, then there are three options for providing this order to the surgery scheduler:

Option 1

• Enter all information into WakeMed Epic.   

Option 2

• Fax the OR Case Request Form AND Pre-Op Orders to the fax line. Raleigh: 919-350-7554 ; Cary: 919-350-2285 ; North: 919-350-6892

Option 3

• Call the Surgery Schedulers at 919-350-7000 and fax the OR Case Request Form to Raleigh: 919-350-7554 ; Cary: 919-350-2285 ; North: 919-350-6892 prior to calling.
• (Please note: Fax program takes a few minutes to receive and catalog the fax. Please allow 10 to 15 minutes before calling so the fax can be received.)
• OR Case Request Form

History & Physical Requirement

A History and Physical (H&P) exam must be completed within 30 days of the scheduled surgery and preferably prior to the Pre-Anesthesia Testing (PAT) visit. All H&P forms must be typed, dictated or entered into WakeMed Epic, signed, dated and timed by the licensed independent provider (LIP). It is important to note that the History and Physical must be current (exam must take place within 30 days of surgery).