Name of the Procedure:

Not Assessed for Psychosis, Depression, Anxiety, Apathy, and Impulse Control Disorder (HCPCS Code G2122)

Summary

The HCPCS code G2122 is used when a healthcare provider has not assessed a patient for specific mental health conditions, including psychosis, depression, anxiety, apathy, and impulse control disorder.

Purpose

This code is used in situations where a documented assessment for these mental health conditions has not been performed during a medical visit.

Goals or Expected Outcomes

• Document the absence of assessment.
• Ensure accurate medical coding and billing.
• Facilitate appropriate follow-up and care planning as needed.

Indications

• A visit during which the healthcare provider did not assess for psychosis, depression, anxiety, apathy, or impulse control disorder.
• Documentation of non-assessment for medical record accuracy.

Patient Criteria or Factors

• The patient may have presented for a different medical issue where mental health assessment was not a focus.
• The provider determined that an assessment for these specific conditions was not necessary during the visit.

Preparation

Since this is a documentation code indicating non-assessment, no specific preparation is required.

Procedure Description

• The healthcare provider conducts the medical visit without assessing the patient for psychosis, depression, anxiety, apathy, or impulse control disorder.
• The provider then documents this non-assessment using HCPCS code G2122 for billing and medical records.

Tools, Equipment, or Technology

• Standard medical record-keeping tools (electronic health record systems or paper charts).

Anesthesia or Sedation

• Not applicable.

Duration

• The time taken to document the non-assessment is minimal, generally a few minutes.

Setting

• This documentation can be performed in any medical setting, including hospitals, outpatient clinics, or private practices.

Personnel

• The primary healthcare provider (e.g., physician, nurse practitioner) responsible for the patient visit.

Risks and Complications

• Common Risks: There are no direct risks associated with documenting non-assessment.
• Rare Risks: If mental health issues are present but remain unassessed, the patient's conditions might go unaddressed, potentially complicating overall care.

Benefits

• Expected Benefits: Accurate documentation for medical records and billing purposes.
• Timeline for Benefits: Immediate, as part of maintaining comprehensive and accurate patient records.

Recovery

• No post-procedure care is required as this is a documentation code.

Alternatives

• Alternative Treatment Options: Comprehensive mental health assessments using appropriate diagnostic tools and procedures.
• Pros and Cons of Alternatives:
  • Comprehensive assessment would provide a more complete understanding of the patient's mental health but may require more time and resources.

Patient Experience

• Since this is a non-assessment documentation code, the patient typically will not have any direct experiences stemming from this specific documentation action.
• If an assessment for mental health conditions is not performed, some patients may benefit from reassurance or explanation as to why it was not necessary during the visit.