Name of the Procedure:

Patient identified as tobacco user did not receive tobacco cessation intervention (counseling and/or pharmacotherapy), reason not given (G9908)

Summary

This notation is used to indicate that a patient recognized as a tobacco user did not receive any form of tobacco cessation intervention, such as counseling or medication, and no specific reason was provided for this omission.

Purpose

The purpose of tracking this procedure code is to document instances where patients who use tobacco do not receive recommended cessation interventions. This information is crucial for quality control and improving healthcare delivery.

Indications

This notation is specifically applied when:

• A patient is identified as a tobacco user.
• No tobacco cessation counseling or pharmacotherapy has been provided.
• No reason is given for the lack of intervention.

Preparation

There is no preparation required for this documentation process. It is typically noted during the clinical encounter.

Procedure Description

1. The healthcare provider identifies the patient as a tobacco user.
2. The provider fails to administer or recommend any cessation interventions.
3. A healthcare professional documents this omission using the specific code G9908.

No tools, equipment, or anesthesia are used as it is a documentation procedure.

Duration

The documentation process typically takes a few minutes during the patient visit.

Setting

This can be documented in any healthcare setting, including hospitals, outpatient clinics, and primary care offices.

Personnel

Typically, this is recorded by:

• Physicians
• Nurses
• Medical assistants
• Electronic health record (EHR) system administrators

Risks and Complications

There are no medical risks associated with the documentation process itself. However, the lack of tobacco cessation intervention can pose health risks to the patient, including continued tobacco use with associated long-term health complications.

Benefits

The main benefit is the accurate documentation of care processes, which can be used to improve healthcare quality and ensure that patients receive appropriate interventions in the future.

Recovery

No physical recovery needed as it is a documentation procedure. However, attention to this documentation might lead to future interventions that can aid in tobacco cessation.

Alternatives

The primary alternative is to provide the recommended tobacco cessation interventions, which include:

• Tobacco cessation counseling.
• Pharmacotherapy (medications that help with cessation).

These alternatives directly address the health risks associated with tobacco use.

Patient Experience

Patients usually are not aware of this documentation process unless it is discussed with them directly. If cessation interventions are not provided, they miss the potential benefits of these treatments, which could aid in quitting tobacco use, improving overall health and reducing the risk of associated diseases.