How To Use HCPCS Code G9658

HCPCS code G9658 describes the use of a transfer of care protocol or handoff tool/checklist that includes the required key handoff elements not being used. This code is used to indicate situations where healthcare providers fail to utilize a standardized tool or checklist during the transfer of care process, potentially leading to gaps in communication and patient safety issues.

1. What is HCPCS G9658?

HCPCS code G9658 is a specific code used in medical coding to identify instances where a transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is not used. This code is essential for tracking and monitoring the adherence to standardized handoff procedures in healthcare settings.

2. Official Description

The official description of HCPCS code G9658 is “Toc tool incl elem not used.” This description succinctly conveys that the transfer of care tool or checklist, which should include the necessary elements for a comprehensive handoff, was not utilized in the specific case being coded.

3. Procedure

1. During the transfer of care process, healthcare providers should have a standardized tool or checklist in place.
2. This tool or checklist should include key handoff elements such as patient identification, relevant medical history, current medications, pending tests or procedures, and any specific instructions or precautions.
3. However, in cases where HCPCS code G9658 is applicable, the healthcare provider failed to use the designated tool or checklist.
4. This omission can result in miscommunication, incomplete information transfer, and potential patient safety risks.
5. It is crucial for healthcare providers to ensure the proper utilization of transfer of care protocols to facilitate effective and safe transitions between healthcare settings.

4. When to use HCPCS code G9658

HCPCS code G9658 should be used when documenting instances where the transfer of care protocol or handoff tool/checklist, which includes the required key handoff elements, is not used. This code is applicable across various healthcare settings, including hospitals, clinics, and long-term care facilities.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9658, healthcare providers need to ensure accurate documentation of the specific case where the transfer of care protocol or handoff tool/checklist was not used. This documentation should include details about the patient, the healthcare providers involved, and any relevant circumstances surrounding the handoff process.

6. Historical Information and Code Maintenance

HCPCS code G9658 was added to the Healthcare Common Procedure Coding System on January 01, 2016. Since its addition, there have been no maintenance actions taken for this code, as indicated by the action code N, which means no maintenance for this code.

7. Medicare and Insurance Coverage

Medicare and other insurance coverage for HCPCS code G9658 may vary. It is essential for healthcare providers to consult the specific guidelines and policies of the respective payers to determine the coverage and reimbursement for this code.

8. Examples

Here are five examples illustrating situations where HCPCS code G9658 would be appropriate:

1. A nurse fails to use the designated handoff tool when transferring a patient from the emergency department to the medical-surgical unit.
2. A physician neglects to utilize the standardized checklist during the transfer of care process for a patient being discharged from the hospital.
3. A paramedic overlooks the use of the handoff tool when transferring a patient from an ambulance to the emergency department.
4. A nurse practitioner forgets to complete the required elements in the handoff checklist when transferring a patient from a primary care clinic to a specialist.
5. A pharmacist fails to utilize the designated transfer of care protocol when handing off medication-related information to another healthcare provider.