Name of the Procedure:

Communication Failure Documentation for Major Depressive Disorder (G8960)

Summary

This documentation procedure captures instances where the clinician treating a patient for major depressive disorder (MDD) does not communicate with the clinician managing a comorbid condition, and no reason is given for this lack of communication.

Purpose

The purpose is to record communication failures between healthcare providers treating different conditions in the same patient, particularly when managing major depressive disorder along with another comorbid condition. This aims to identify gaps in communication for quality improvement and ensure comprehensive patient care.

Indications

• Patients diagnosed with major depressive disorder.
• Presence of another comorbid medical or psychiatric condition.
• Instances where the clinician treating MDD did not communicate with the clinician treating the comorbid condition, and no reason was documented.

Preparation

No specific patient preparation is required as this is a documentation procedure.

Procedure Description

1. Identify the patient diagnosed with major depressive disorder and a comorbid condition.
2. Review patient records to verify if the clinician treating MDD communicated with the clinician managing the comorbid condition.
3. If no communication was documented and no reason for this communication failure was provided, use the HCPCS code G8960 to record this.
4. Ensure that this documentation is included in the patient's health records for quality monitoring purposes.

Duration

The documentation process typically takes a few minutes.

Setting

The procedure is performed in any healthcare setting where patient records are managed, such as hospitals, outpatient clinics, or primary care offices.

Personnel

Healthcare professionals involved may include:

• Physicians
• Nurses
• Medical coders
• Administrative staff

Risks and Complications

• There are no direct risks or complications associated with the documentation procedure itself.
• Failing to document communication failures may result in inadequate care coordination and potential harm to the patient.

Benefits

• Improved awareness and tracking of communication gaps can lead to better care coordination.
• Identifying these gaps enables healthcare facilities to implement corrective measures and improve overall patient outcomes.

Recovery

• Not applicable to the patient as this is a documentation task.

Alternatives

• Implementing direct communication between clinicians (e.g., through electronic health records or meeting protocols) to ensure comprehensive patient management.
• Using other tracking or quality monitoring systems to identify and rectify communication gaps.

Patient Experience

• As this is an administrative documentation task, the patient is typically not directly involved or affected during the process.
• Indirectly, better documentation and subsequent improvements in communication can enhance the patient's overall healthcare experience.