Name of the Procedure:

Functional status not performed, reason not otherwise specified (G9918)

Summary

In simple terms, this code is used to indicate that a patient's functional status assessment was not performed, and the reason for not doing so was not specified.

Purpose

The purpose of using this code is to document instances where the functional status of a patient (which is a measure of their ability to perform activities of daily living) was not assessed. It helps in keeping a record for quality reporting and monitoring purposes.

Indications

There aren't specific symptoms or conditions directly warranting this code itself, but it is used when there is a failure to perform a functional status assessment for reasons that are not clearly stated. It generally applies to patients who were supposed to have their functional status evaluated but did not, without a documented reason.

Preparation

No specific preparation is required for the use of this code as it pertains to the absence of a procedure rather than the execution of one.

Procedure Description

As this code represents the non-performance of an assessment:

• No physical procedure is carried out.
• There are no tools, equipment, technology, anesthesia, or sedation involved.
• It simply involves marking the patient record appropriately when the functional status assessment was not conducted for unspecified reasons.

Duration

Not applicable, as there is no procedure conducted.

Setting

The non-performance of the procedure can be documented in any healthcare setting where functional status assessments are typically conducted, including hospitals, outpatient clinics, or nursing facilities.

Personnel

Healthcare professionals who would be responsible for documenting this include:

• Physicians
• Nurses
• Medical coders and record keepers

Risks and Complications

Documenting the non-performance of a functional status assessment has the following risks:

• Potential for incomplete patient records.
• Missed opportunities for identifying functional impairments.
• Possible delays in appropriate care interventions for affected patients.

Benefits

Using this code:

• Ensures transparency in patient records.
• Supports quality monitoring and reporting.
• Helps in identifying gaps in patient care.

Recovery

Not applicable, as there is no physical procedure performed.

Alternatives

If the functional status assessment can be performed later, it should be. No alternative coding applies when the assessment simply hasn't been done for unspecified reasons.

Patient Experience

Since there is no physical procedure performed, the patient will not feel or experience anything different than usual care. However, patients might miss the benefit of having their functional status assessed and managed appropriately.