Name of the Procedure:

Pain Assessment Documented as Positive, Follow-Up Plan Not Documented, Documentation the Patient is Not Eligible at the Time of the Encounter (HCPCS Code G8939)

Summary

This procedure involves documenting instances where a pain assessment indicates that pain is present, but a follow-up plan is not created because the patient is deemed not eligible for such a plan at the time of the encounter.

Purpose

This documentation serves to record the presence of pain and the decision-making process regarding the follow-up, ensuring that all patient care details are accurately logged. It helps track patients who need pain management and those who are not eligible for follow-up plans at the time of the assessment.

Indications

• Documentation is required when a patient reports pain during an assessment.
• The patient is determined to be ineligible for a follow-up plan due to certain criteria (e.g., end-of-life, different treatment priorities).

Preparation

• No specific preparation is needed for the documentation itself.
• The patient must undergo a pain assessment evaluating pain levels and its impact on daily functions.

Procedure Description

1. Pain Assessment: The healthcare provider conducts a standard pain assessment using questionnaires, scales, or interviews.
2. Documentation: Pain is documented as positive if present.
3. Evaluation of Eligibility: The provider assesses whether the patient is eligible for a follow-up plan.

4. Non-Eligibility Documentation: If the patient is not eligible, the provider documents the reasons for ineligibility.

   Tools: Standard pain assessment tools (e.g., Numeric Pain Rating Scale, Visual Analog Scale).

   No anesthesia or sedation is involved.

Duration

The documentation process typically takes a few minutes, following the pain assessment which may last 10-15 minutes.

Setting

This documentation is often performed in settings such as:

• Hospitals
• Outpatient clinics
• Primary care offices
• Specialized pain management centers

Personnel

• Physicians
• Nurses
• Physician Assistants
• Nurse Practitioners

Risks and Complications

This documentation procedure itself poses no risks or complications to the patient.

Benefits

• Ensures accurate patient records.
• Helps in quality improvement measures and ensuring compliance with care standards.
• Provides clarity on the patient's care pathway, especially in complex cases.

Recovery

No recovery is necessary since this is a documentation process rather than a physical procedure.

Alternatives

• Regular pain assessment without specific documentation of ineligibility.
• Follow-up plan documentation if the patient becomes eligible in future assessments.

Patient Experience

• The patient will undergo a pain assessment as part of routine clinical care.
• There should be no additional discomfort beyond standard medical questioning and interaction with the healthcare provider.
• Pain management strategies, if applicable, will be discussed and documented according to patient eligibility.