Name of the Procedure:

HCPCS G9921 - No Screening Performed, Partial Screening Performed, or Positive Screen Without Recommendations and Reason Not Given or Otherwise Specified

Summary

This procedure code is used to report circumstances where no medical screening was done, a screening was only partially completed, or a positive screening result was found but no follow-up recommendations were provided, and no reason is given or specified for these actions.

Purpose

The purpose of documentation using this procedure code is to accurately reflect the actions taken during a patient’s medical screening process. It is important for healthcare quality assessments, tracking patient care, and for insurance billing purposes.

Indications

This code is applicable in situations where:

• No screening was performed when it was indicated.
• A screening was not fully completed.
• A positive result was obtained from a screening but no further recommendations were made.

Preparation

No specific patient preparation is required since this code is descriptive of a process outcome rather than a procedure.

Procedure Description

This code is used for documentation purposes and does not involve any specific step-by-step procedure. It denotes the outcome where either:

• No screening was conducted.
• The screening was incomplete.

• A positive screening result was obtained without follow-up recommendations.

  Duration

  Not applicable as this code does not involve an active procedure.

Setting

Applicable in any medical setting where patient screenings are conducted, including hospitals, outpatient clinics, and primary care offices.

Personnel

Medical personnel involved could include:

• Physicians
• Nurses
• Medical assistants
• Administrative staff (for documentation purposes)

Risks and Complications

The use of this code indicates a lack of action or incomplete action, which inherently carries risks such as:

• Missed diagnoses, leading to untreated conditions.

• Delay in appropriate care or intervention.

  Benefits

• Accurate record-keeping for quality control and auditing purposes.

• Helps in identifying gaps in care processes for improvement.

  Recovery

  Not applicable as there is no direct procedure performed on the patient.

Alternatives

The main alternative is to ensure that complete and appropriate screenings are conducted, and positive results are accompanied by follow-up recommendations. This includes:

• Comprehensive screenings as per guidelines.
• Detailed documentation of reasons for any deviations from the usual screening process.

Patient Experience

Given that this code is about documentation rather than an actual procedure, the patient experience would typically involve only the emotional or physical impact of not having a conclusive screening process and potentially facing uncertainties regarding their health status. Pain management and comfort measures would be contingent on any underlying conditions identified or missed due to the incomplete screening.