Name of the Procedure:

• Common Name(s): Depression Screening Not Completed
• Technical or Medical Terms: HCPCS Code G8433

Summary

This documentation code is used when a scheduled screening for depression has not been completed due to a documented reason such as patient refusal, dementia, language barriers, or other specific barriers.

Purpose

• Medical Conditions/Problems: This procedure addresses situations where a depression screening was planned but unmet due to extenuating circumstances.
• Goals/Expected Outcomes: The goal is to ensure proper documentation when the screening cannot be completed, which aids in accurate patient records, billing, and quality of care tracking.

Indications

• Symptoms/Conditions Warranting the Procedure: The patient has been scheduled for a depression screening but encounters barriers preventing its completion.
• Patient Criteria: Patients who show potential signs of depression but cannot complete the screening due to documented reasons.

Preparation

• Pre-Procedure Instructions: No specific preparation is needed as the actual screening does not occur.
• Diagnostic Tests/Assessments: The procedure involves noting why the screening was not completed.

Procedure Description

• Steps Involved:
  1. Attempt to initiate the depression screening.
  2. Identify the reason why the screening cannot be completed.
  3. Document the specific reason using the HCPCS code G8433.
• Tools, Equipment, or Technology: Standard medical records system for documentation.
• Anesthesia or Sedation: Not applicable.

Duration

• The time to document the reason for non-completion typically takes a few minutes.

Setting

• This documentation takes place wherever the initial screening attempt occurs, such as a hospital, outpatient clinic, or primary care office.

Personnel

• Healthcare Professionals Involved: Primary care physicians, nurses, or mental health professionals responsible for the patient's care and documentation.

Risks and Complications

• Common and Rare Risks: There are no direct physical risks associated with this documentation.
• Possible Complications: Potential for inaccuracies in patient records if the reason for non-completion is not properly documented.

Benefits

• Expected Benefits: Accurate medical records, improved patient care, compliance with healthcare standards.
• Realization Time: Immediately upon proper documentation.

Recovery

• Post-Procedure Care and Instructions: None required.
• Recovery Time: Not applicable.
• Restrictions or Follow-Up Appointments: Follow-up will depend on the patient's overall mental health care plan and identified barriers.

Alternatives

• Other Treatment Options: Ensuring other forms of mental health assessments or support are provided if standard screening is not possible.
• Pros and Cons of Alternatives: Alternatives may provide different insights into the patient’s mental health status but might not be standardized like the initial screening.

Patient Experience

• During the Procedure: They might feel frustrated or concerned if they are unable to complete a depression screening.
• Pain Management and Comfort Measures: Not applicable as this is a non-invasive process of documentation. Mental health support should be offered if the reason for non-completion involves emotional distress.