Name of the Procedure:

Common name(s): Other physical or occupational therapy Technical or medical terms: Subsequent functional limitation, discharge status, at discharge from therapy or to end reporting (HCPCS G8995)

Summary

This procedure involves assessing a patient's functional limitations at the time they are discharged from physical or occupational therapy. The evaluation helps healthcare providers report and understand the patient’s progress and remaining limitations.

Purpose

• Medical Conditions or Problems Addressed: This procedure targets patients who have undergone physical or occupational therapy for various conditions including post-surgical recovery, chronic pain, mobility issues, and rehabilitation after injury.
• Goals or Expected Outcomes: The primary goal is to evaluate the patient's functional status upon discharge, ensuring that therapy has met its objectives and to identify any remaining limitations that might need further attention.

Indications

• Specific Symptoms or Conditions: This procedure is performed when a patient is being discharged from a course of physical or occupational therapy.
• Patient Criteria: It is appropriate for patients who have completed their therapy regimen and require an assessment to document their progress and remaining functional limitations.

Preparation

• Pre-procedure Instructions: No special preparation is typically required for this assessment. Patients may be advised to wear comfortable clothing and bring any mobility aids they normally use.
• Diagnostic Tests or Assessments: No additional tests are typically required beyond the standard assessment tools used in physical or occupational therapy.

Procedure Description

1. Initial Interview: The therapist reviews the patient's medical history and therapy progress.
2. Functional Assessment: The therapist conducts a series of standardized tests to evaluate the patient's strength, flexibility, mobility, and any other relevant functional limitations.
3. Documentation: The results are recorded using specific coding (HCPCS G8995) to capture the discharge status.
4. Final Consultation: The therapist provides feedback to the patient and discusses any ongoing care or follow-up needs.

Tools and Equipment Used:

• Standardized assessment tools and questionnaires
• Possibly assistive devices like gait belts, balance boards, or resistance bands

Anesthesia or Sedation: Not applicable.

Duration

The assessment typically takes about 30 to 60 minutes.

Setting

This procedure is commonly performed in:

• Outpatient clinics
• Rehabilitation centers
• Hospitals

Personnel

• Licensed Physical Therapists (PTs)
• Licensed Occupational Therapists (OTs)
• Therapy assistants may be involved for supportive tasks

Risks and Complications

• Common Risks: Minimal risks; mild discomfort during physical assessment.
• Rare Risks: Unlikely to have complications but could include exacerbation of pain or fatigue.

Benefits

• Expected Benefits: Provides a clear understanding of the patient’s functional status at discharge, which aids in planning future care.
• Timeline for Benefits: Immediate insights post-assessment.

Recovery

• Post-procedure Care: Usually no special care is required post-assessment.
• Expected Recovery Time: No recovery time; patients can resume normal activities immediately.
• Follow-up: Based on the findings, further follow-up appointments may be scheduled.

Alternatives

• Other Treatment Options: Alternatives include continuing therapy without a discharge assessment or proceeding with home exercise programs without formal evaluation.
• Pros and Cons: The discharge assessment provides valuable data that supports quality care and appropriate future interventions. Skipping this step might lead to less-informed decisions regarding the patient's ongoing health needs.

Patient Experience

• During the Procedure: Patients might experience mild discomfort during certain physical tests. The overall process is typically straightforward.
• Pain Management and Comfort Measures: The therapist will ensure patient comfort and address any pain experienced during the assessment with appropriate measures.