Name of the Procedure:

Other Physical or Occupational Therapy Primary Functional Limitation, Projected Goal Status, at Therapy Episode Outset, at Reporting Intervals, and at Discharge or to End Reporting (G8991)

Common Name(s): Physical/Occupational Therapy Functional Status Assessment

Technical or Medical Terms: HCPCS G8991, Functional Limitation Reporting

Summary

This procedure involves assessing the patient's primary functional limitations related to physical or occupational therapy. The assessment is conducted at the start of the therapy episode, during regular intervals, and at discharge or the end of reporting.

Purpose

The primary purpose of this procedure is to monitor and document the progress of patients undergoing physical or occupational therapy. This helps therapists to customize and adjust treatment plans to meet the patient's therapeutic goals.

Indications

• Patients experiencing reduced mobility or functional impairments.
• Individuals undergoing rehabilitation post-surgery or injury.
• Chronic conditions causing functional limitations, such as arthritis or stroke.

Preparation

• No specific fasting or medication adjustments are usually required.
• The patient should wear comfortable clothing.
• Preliminary functional assessments or diagnostic tests might be conducted.

Procedure Description

1. The therapist conducts an initial assessment to determine the patient’s primary functional limitations.
2. A projected goal status is established, outlining the expected functional outcomes.
3. Follow-up assessments are performed at designated reporting intervals to track progress.

4. A final assessment is completed at discharge or the end of the reporting period to evaluate overall improvement and goal attainment.

   Tools: Standardized functional assessment tools and questionnaires.

Anesthesia/Sedation: Not applicable.

Duration

The initial assessment and follow-up evaluations each typically take about 30 to 60 minutes.

Setting

• Outpatient clinic
• Rehabilitation center
• Hospital

Personnel

• Licensed physical or occupational therapists.
• Support staff may assist in documentation.

Risks and Complications

• Generally, no significant risks or complications.
• Practitioner-dependent variability in assessment accuracy.

Benefits

• Tailored therapy plans based on accurate functional assessments.
• Improved tracking of patient progress.
• Enhanced patient outcomes due to personalized treatment adjustments.

Recovery

• No recovery time is needed.
• Patients continue their therapy based on the assessments and may be given home exercises or instructions.

Alternatives

• Manual assessments or subjective evaluations by the therapist without standardized tools.
• Self-reported functional status by the patient without professional evaluation.

Pros: Alternatives may be quicker and require less specialized training. Cons: Less accuracy and consistency in tracking patient progress.

Patient Experience

• Patients may experience some physical exertion during assessments.
• Any discomfort should be discussed with the therapist for adjustments.
• Ongoing communication ensures the patient’s comfort and understanding of their progress.