Name of the Procedure:

Functional Outcome Assessment Documented, Care Plan Not Documented, Documentation that the Patient is Not Eligible for a Care Plan at the Time of the Encounter
Common Name: Functional Assessment
HCPCS Code: G9227

Summary

In this procedure, a healthcare professional documents a functional outcome assessment for a patient. However, based on certain criteria, it is determined and documented that the patient is not eligible for a care plan at the time of the encounter.

Purpose

Medical Conditions/Problems Addressed:

• Evaluation of the patient's functional abilities, such as mobility, self-care, and cognitive functions.

Goals/Expected Outcomes:

• To assess the patient's functional status accurately.
• To determine the necessity of a care plan based on the functional assessment.
• To document that a care plan is not created because the patient is not currently eligible.

Indications

Symptoms/Conditions Warranting the Procedure:

• Recent injury or surgery affecting mobility.
• Chronic illnesses impacting physical or cognitive functions.
• Age-related functional decline.

Patient Criteria:

• Patients undergoing routine follow-up for chronic conditions.
• Newly diagnosed patients with functional impairments.
• Patients who do not meet criteria for an immediate care plan based on their functional assessment.

Preparation

Pre-Procedure Instructions:

• No special preparation required.
• Patients should bring any mobility aids they regularly use (e.g., canes, walkers).
• Patients may be asked to complete questionnaires related to their daily activities and functions.

Diagnostic Tests/Assessments:

• Usually, no additional diagnostic tests are required beforehand.
• Previous medical records and functional assessments may be reviewed.

Procedure Description

Step-by-Step Explanation:

1. The healthcare professional conducts a functional outcome assessment, which may include various standardized tests.
2. Measurements of physical abilities, such as walking speed, balance, and strength, are taken.
3. Cognitive functions may also be assessed through standardized questionnaires.
4. The results are recorded and analyzed.
5. Based on the results, it is documented that the patient is not eligible for a care plan at that time.
6. This decision, along with the assessment details, is included in the patient's medical record.

Tools and Equipment:

• Standardized functional assessment tools (e.g., gait analysis equipment, questionnaires).
• No specialized equipment required.

Anesthesia/Sedation:

• Not applicable.

Duration

• Typically takes about 30-45 minutes.

Setting

• Outpatient clinic or primary care office.

Personnel

• Conducted by a healthcare professional, such as a physical therapist, nurse, or physician.

Risks and Complications

Common Risks:

• Minimal risk involved.
• Possible discomfort during physical assessments.

Rare Risks:

• None significant.

Possible Complications:

• None anticipated.

Benefits

Expected Benefits:

• Provides a comprehensive assessment of the patient's functional status.
• Helps in making informed decisions about the need for care planning.

Realization Timeline:

• Immediate benefits in terms of understanding the patient's functional abilities.

Recovery

Post-Procedure Care:

• No specific post-procedure care required.

Recovery Time and Restrictions:

• No recovery time needed.
• Patients can resume their normal activities immediately.

Alternatives

Other Treatment Options:

• Direct care plan creation without a formal functional assessment.
• Other types of medical evaluations like a comprehensive geriatric assessment.

Pros and Cons:

• Pros: Tailored functional assessment ensures that the patient's needs are accurately documented.
• Cons: May involve more time compared to a straightforward care plan.

Patient Experience

During the Procedure:

• The patient may experience mild fatigue or discomfort from physical assessments.
• The process involves answering questions and performing simple physical tasks.

After the Procedure:

• Patients generally feel normal after the assessment.
• Pain management is not typically necessary.

Comfort measures, such as taking breaks during the assessment, can help ensure patient comfort.