Documentation of patient reason(s) for not prescribing warfarin or another fda-approved oral anticoagulant that is fda approved for the prevention of thromboembolism (e.g., patient choice of having atrial appendage device placed)
HCPCS code
HCPCS Procedure Documentation for Not Prescribing Warfarin or Another FDA-Approved Oral Anticoagulant - Code G8969
Name of the Procedure:
- Common Name: Documentation of Patient's Reason for Not Prescribing Anticoagulants
- Technical/Medical Terms: G8969 Documentation for FDA-Approved Oral Anticoagulant Non-Prescription
Summary
This documentation records a patient's reason(s) for not being prescribed warfarin or another FDA-approved oral anticoagulant for preventing thromboembolism. This can include patient preference for an alternative treatment like the placement of an atrial appendage device.
Purpose
- Conditions Addressed: Thromboembolism prevention.
- Goals/Expected Outcomes: Ensure comprehensive documentation of patient decisions regarding blood clot prevention strategies, particularly for those who choose alternatives to oral anticoagulants.
Indications
- Specific Symptoms/Conditions: Patients at risk for thromboembolism who choose not to use FDA-approved oral anticoagulants.
- Patient Criteria: Patients who express a preference for other preventive measures, such as an atrial appendage device, due to personal, medical, or risk-related reasons.
Preparation
- Pre-Procedure Instructions: No specific preparations required for this documentation process.
- Diagnostic Tests/Assessments: Discussion with healthcare providers regarding anticoagulant options and alternatives.
Procedure Description
- Step-by-Step Explanation:
- Patient consults with healthcare professional about thromboembolism prevention options.
- Healthcare professional discusses the benefits and risks of warfarin and other FDA-approved oral anticoagulants.
- Patient expresses a preference for an alternative measure (e.g., atrial appendage device).
- Healthcare professional documents the patient's reason(s) for selecting the alternative option.
- Tools and Equipment: Digital or paper medical records for documentation.
- Anesthesia/Sedation: Not applicable.
Duration
- Time Required: Generally a 15-30 minute discussion and documentation process.
Setting
- Location: Can be completed in various healthcare settings such as clinics, hospitals, or physician offices.
Personnel
- Healthcare Professionals: Primarily involving a physician or a nurse practitioner.
Risks and Complications
- Common Risks: None associated with documentation.
- Possible Complications: None specific to documentation, although choosing alternatives like the atrial appendage device has its own set of risks which should be discussed separately.
Benefits
- Expected Benefits: Clear and thorough record of patient choice ensuring alignment with their preferences and medical history.
- Realization Time: Immediate, upon completion of the documentation.
Recovery
- Post-Procedure Care: Not applicable as this is a documentation process.
- Expected Recovery Time: Immediate, as there is no physical recovery involved.
Alternatives
- Other Treatment Options: Warfarin, other oral anticoagulants, dual antiplatelet therapy.
- Pros and Cons: Alternatives may offer different benefits and risks; the documentation captures the rationale for the chosen therapy.
Patient Experience
- During the Procedure: Discussion with healthcare provider, may involve expressing concerns and preferences.
- After the Procedure: Peace of mind from having medical choices documented and respected.
- Pain Management/Comfort Measures: Not applicable.