Screening for depression documented as positive, a follow-up plan not completed, documented reason
HCPCS code
Name of the Procedure
Screening for Depression Documented as Positive, Follow-Up Plan Not Completed, Documented Reason
Common Name(s): Depression Screening, Mental Health Assessment, Psychological Evaluation
Technical or Medical Terms: HCPCS Code G8940, Positive Depression Screening without Follow-Up
Summary
This medical procedure involves screening a patient for depression and documenting a positive result. However, it also notes that a follow-up plan was not completed due to a documented reason.
Purpose
Addresses: Depression, Mental Health Concerns, Emotional Well-being
Goals/Outcomes: To identify patients with depression and understand the obstacles preventing immediate follow-up care, ultimately aiming to improve mental health management and patient care plans.
Indications
Symptoms/Conditions: Feelings of sadness, lack of interest in activities, changes in appetite or sleep, fatigue, difficulty concentrating, suicidal thoughts
Patient Criteria: Any patient displaying symptoms of depression, or those in at-risk groups such as individuals with chronic illnesses, experiencing significant life changes, or those with a family history of depression.
Preparation
Pre-procedure Instructions: Patients typically require no special preparation. They should be informed about the nature and purpose of the depression screening.
Diagnostic Tests: No specific tests are required before the screening; however, a clinical interview and standardized questionnaire (e.g., PHQ-9) may be used.
Procedure Description
- Interview/Questionnaire: The healthcare provider conducts an interview or provides a standardized questionnaire to assess symptoms of depression.
- Scoring: The responses are scored to determine if the patient has depression.
- Documentation: If the screening result is positive, the healthcare provider documents the score and the positive result.
- Reason for No Follow-Up: The provider also documents the reason for not completing a follow-up plan, which could include patient refusal, absence of patient, or other clinical judgments.
Tools/Equipment: Standardized screening tools (e.g., PHQ-9 questionnaire), medical records for documentation.
Anesthesia/Sedation: Not applicable.
Duration
Typical Time: The entire screening process usually takes about 10-15 minutes.
Setting
Location: Typically performed in various healthcare settings such as hospitals, outpatient clinics, primary care offices, or mental health facilities.
Personnel
Involved Professionals: Primary care physicians, nurses, mental health professionals such as psychologists or psychiatrists, and possibly clinical social workers.
Risks and Complications
Common Risks: Emotional distress during the assessment. Rare Risks: Misdiagnosis if the patient is not accurately assessed. Management of Complications: Referring the patient to a mental health specialist for further evaluation if there are any concerns.
Benefits
Expected Benefits: Early identification of depression symptoms which allows for timely intervention and management. Understanding and documenting reasons for lack of follow-up can help in addressing barriers to mental health care. Timeline for Benefits: Immediate benefits from the screening process, potential long-term benefits from any subsequent care arranged.
Recovery
Post-Procedure Care: No specific aftercare is required following the screening procedure itself. Recovery Time: Not applicable. Restrictions/Follow-Up: Patients may be advised to follow up with a mental health professional or primary care provider, depending on their symptoms and documented reasons for not having an immediate follow-up plan.
Alternatives
Other Treatment Options: Regular consultations with mental health professionals, pharmacotherapy, psychotherapy, lifestyle modifications, supportive care from family and friends. Pros & Cons of Alternatives: Alternatives may offer more immediate care but might not address the reasons why the follow-up wasn't initially completed.
Patient Experience
What to Expect: Patients may feel emotionally vulnerable or exposed during and after the screening. It's crucial that they are reassured about the confidentiality of their responses. Pain Management/Comfort Measures: Emotional support from the healthcare provider, providing avenues for follow-up to discuss mental health concerns further.