Name of the Procedure:

Common Name(s): Documentation of Medical Reasons for Not Screening for Tobacco Use
Technical or Medical Term: HCPCS Code G9904

Summary

This procedure involves documenting the medical reasons why a healthcare provider has decided not to screen a patient for tobacco use. Reasons may include limited life expectancy or other significant medical conditions.

Purpose

Medical Conditions or Problems Addressed:

• Situations where screening for tobacco use is not appropriate due to severe health conditions or other extenuating circumstances.

Goals or Expected Outcomes:

• To accurately document the rationale behind not conducting a tobacco use screening to ensure comprehensive medical records and compliance with healthcare standards.

Indications

Specific Symptoms or Conditions:

• Patients with a limited life expectancy.
• Patients with significant medical reasons that make screening irrelevant or inappropriate.

Patient Criteria or Factors:

• Patients with terminal illnesses.
• Patients where the healthcare provider deems it medically unnecessary or potentially harmful to conduct a tobacco use screening.

Preparation

Pre-Procedure Instructions:

• No specific preparation is needed from the patient.

Diagnostic Tests or Assessments:

• Evaluation of the patient's overall health condition and life expectancy.

Procedure Description

Step-by-Step Explanation:

1. The healthcare provider evaluates the patient's medical condition.
2. If deemed inappropriate to screen for tobacco use, the provider documents the specific medical reasons in the patient’s medical record.
3. The documentation should include a detailed explanation supporting the rationale.

Tools, Equipment, or Technology Used:

• Electronic Health Record (EHR) systems or patient charts.

Anesthesia or Sedation Details:

• Not applicable.

Duration

Typical Duration:

• Typically takes a few minutes.

Setting

Where Performed:

• Can be performed in any healthcare setting including hospitals, outpatient clinics, and private practices.

Personnel

Healthcare Professionals Involved:

• Primary care physicians, specialists, nurses.

Risks and Complications

Common and Rare Risks:

• There are no direct risks associated with the documentation procedure itself as it is a non-invasive administrative task.

Possible Complications and Their Management:

• Complications are generally related to the underlying medical conditions and not this administrative procedure.

Benefits

Expected Benefits:

• Ensures accurate medical record-keeping.
• Helps in maintaining compliance with healthcare standards and policies.

Realization of Benefits:

• Benefits are immediate once the documentation is completed.

Recovery

Post-Procedure Care and Instructions:

• No specific post-procedure care is needed.

Expected Recovery Time:

• Not applicable.

Restrictions or Follow-Up Appointments:

• Follow-ups are based on the patient's primary medical conditions and care plan.

Alternatives

Other Treatment Options Available:

• Proceeding with a tobacco use screening if the circumstances change and it becomes appropriate.

Pros and Cons of Alternatives:

• Screening for tobacco use could provide valuable health insights if the patient’s condition improves; however, it may be unnecessary or harmful under the current circumstances.

Patient Experience

During the Procedure:

• The patient may be informed about the decision and the reasons for not undergoing the screening.

Post-Procedure:

• The patient is likely to continue their ongoing treatment without additional intervention related to tobacco use screening.
• Pain Management: Not applicable since this is a documentation procedure.