Name of the Procedure:

Safety Concerns Screening Not Provided
Technical Term: HCPCS Code G9925

Summary

This code is used in medical records when a healthcare safety concerns screening, which typically assesses potential risks or hazards to a patient's health, is not provided. It specifically acknowledges that the reason the screening was not provided does not fall into a predefined category.

Purpose

Medical Conditions or Problems It Addresses: The code indicates situations where a safety concerns screening is expected but was not conducted for reasons not otherwise specified.

Goals or Expected Outcomes: The aim is to ensure proper documentation when safety concerns screening is omitted, which is crucial for patient safety and quality reporting.

Indications

Specific Symptoms or Conditions:

• No specific symptoms or conditions; it is more about the omission of a standard screening process.

  Patient Criteria or Factors:

• Applicable to any patient for whom a safety concerns screening is standard but was not conducted.

Preparation

No specific preparation is required from the patient, as the code is related to documentation rather than an actual procedure.

Procedure Description

There is no physical procedure involved. This code is used for documentation when the standard practice of screening for safety concerns is not performed.

Duration

Not applicable.

Setting

The setting would typically be wherever safety concerns screenings are part of the standard care, such as hospitals, outpatient clinics, or primary care offices.

Personnel

No personnel are directly involved in the administration of this code. It may be noted by any healthcare provider responsible for patient documentation.

Risks and Complications

Common Risks:

• Potential for untreated safety risks to impact patient health.

  Rare Risks:

• Documentation errors or miscommunications.

Possible Complications and Their Management:

• Ensure accurate follow-up documentation and patient safety reviews if the screening was omitted.

Benefits

Ensures accurate documentation of why safety screenings were not conducted, which helps in overall patient safety and quality care monitoring.

Recovery

Not applicable, as no physical procedure is involved.

Alternatives

There are no direct alternatives to this documentation code, but continuous efforts to perform safety concerns screenings can avoid the need to use this code.

Pros and Cons of Alternatives:

• Pros: Conducting the actual safety concerns screening ensures patient safety and comprehensive care.
• Cons: Ongoing adherence to screening schedules may require additional time and resources.

Patient Experience

Most patients will not be directly aware of this documentation code. It serves as an internal tool for healthcare providers to ensure accurate and thorough documentation of care.

Pain Management and Comfort Measures: Not applicable.