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:
  1. Patient consults with healthcare professional about thromboembolism prevention options.
  2. Healthcare professional discusses the benefits and risks of warfarin and other FDA-approved oral anticoagulants.
  3. Patient expresses a preference for an alternative measure (e.g., atrial appendage device).
  4. 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.