Name of the Procedure:

Common Name(s): Pneumococcal Vaccine Not Administered

Medical Term: HCPCS Code G8867

Summary

This code indicates that a pneumococcal vaccine, which protects against pneumococcal infections, was not given to the patient, and no reason for withholding the vaccine was documented.

Purpose

The primary purpose of this documentation is for healthcare providers and insurers to track instances where a pneumococcal vaccine was not administered without a given reason. This data can help ensure proper medical practice and vaccine coverage.

Goals and Expected Outcomes:

• Ensure appropriate vaccine documentation.
• Identify potential gaps in vaccine administration.

Indications

• The patient was eligible for the pneumococcal vaccine but did not receive it.
• No documented medical reasons or contraindications provided for not administering the vaccine.

Patient Criteria:

• Adults who are at risk of pneumococcal diseases, typically older adults or those with chronic health conditions.

Preparation

There is no special preparation required for the patient as this code merely documents the lack of vaccine administration.

Procedure Description

The procedure involves checking a patient's medical records and noting that a pneumococcal vaccine was not administered without a stated reason.

• Tools/Equipment: Patient health record system.
• No anesthesia or sedation is involved since this is a documentation code.

Duration

The documentation process typically takes a few minutes to complete during a medical visit or record review.

Setting

This documentation can be done in various healthcare settings, including:

• Hospitals
• Outpatient clinics
• Primary care offices

Personnel

The following healthcare providers might be involved in documenting this code:

• Physicians
• Nurses
• Medical assistants
• Administrative staff

Risks and Complications

• Risks: There are no direct risks to the patient from the documentation process itself.
• Complications: The main concern is missed opportunities for vaccination, potentially leading to increased risk of pneumococcal infections.

Benefits

Proper documentation helps ensure follow-up actions to administer the vaccine are taken and allows for better management of public health records.

Recovery

Since this is a documentation code, there are no post-procedure care or recovery instructions related to the patient.

Alternatives

Alternative Documentation Codes:

• G8866: Pneumococcal vaccine not administered for documented reasons.
• No alternatives are equivalent to the actual administration of the vaccine.

Pros and Cons:

• The alternative codes provide reasons for not administering the vaccine, which is beneficial for medical audits and patient care planning.

Patient Experience

The patient should be informed verbally that the pneumococcal vaccine was not given and recommended to discuss the importance of vaccination.

Pain Management and Comfort Measures:

• Not applicable as this is purely a documentation process.