How To Use HCPCS Code G1001

HCPCS code G1001 describes a clinical decision support mechanism called evicore, which is defined by the Medicare Appropriate Use Criteria (AUC) program. This code is used to identify and bill for the use of evicore in medical care settings. In this article, we will explore the details of HCPCS code G1001, including its official description, procedure, when to use it, billing guidelines, historical information, Medicare and insurance coverage, and provide examples of when this code should be billed.

1. What is HCPCS G1001?

HCPCS code G1001 is a specific code used to identify the clinical decision support mechanism evicore. This mechanism is defined by the Medicare Appropriate Use Criteria (AUC) program. It is an important tool used in medical care settings to assist healthcare providers in making informed decisions about the appropriate use of medical services and procedures.

2. Official Description

The official description of HCPCS code G1001 is “Clinical decision support mechanism evicore, as defined by the Medicare appropriate use criteria program.” The short description for this code is “Cdsm evicore.”

3. Procedure

1. Healthcare providers utilize the evicore clinical decision support mechanism to assist in making appropriate use decisions for medical services and procedures.
2. The provider accesses the evicore system, either through an online platform or integrated software within their electronic health record system.
3. The provider enters relevant patient information, such as the patient’s medical history, symptoms, and any diagnostic test results.
4. The evicore system analyzes the inputted information and provides evidence-based recommendations or guidelines for the appropriate use of medical services or procedures.
5. The provider reviews the recommendations provided by evicore and uses them to guide their clinical decision-making process.
6. The provider documents the use of evicore in the patient’s medical record for billing and auditing purposes.

4. When to use HCPCS code G1001

HCPCS code G1001 should be used when healthcare providers utilize the evicore clinical decision support mechanism to assist in making appropriate use decisions for medical services and procedures. It is important to note that the use of evicore is specific to the Medicare Appropriate Use Criteria (AUC) program and may have specific eligibility criteria or guidelines for use.

5. Billing Guidelines and Documentation Requirements

When billing for the use of HCPCS code G1001, healthcare providers should ensure that they document the use of the evicore clinical decision support mechanism in the patient’s medical record. This documentation should include the date and time of use, the specific recommendations or guidelines provided by evicore, and any actions taken by the provider based on those recommendations.

6. Historical Information and Code Maintenance

HCPCS code G1001 was added to the Healthcare Common Procedure Coding System on January 01, 2020. As of the effective date, there have been no maintenance actions taken for this code, as indicated by the action code N, which means no maintenance for this code. It is important to stay updated with any future changes or revisions to the code.

7. Medicare and Insurance Coverage

Medicare and insurance coverage for HCPCS code G1001 may vary. The pricing indicator code for this code is 00, which indicates that the service is not separately priced by Part B. This means that the service may be bundled with other services or not covered by Medicare or other insurers. The multiple pricing indicator code is 9, which means that the value for this code is not established. It is important for healthcare providers to verify coverage and reimbursement policies with the respective payers.

8. Examples

Here are five examples of scenarios where HCPCS code G1001 may be billed:

1. A primary care physician uses the evicore clinical decision support mechanism to determine the appropriate imaging study for a patient with lower back pain.
2. An orthopedic surgeon consults the evicore system to guide their decision on whether a patient with knee osteoarthritis is a suitable candidate for knee replacement surgery.
3. A cardiologist utilizes evicore to determine the appropriate cardiac imaging study for a patient with suspected coronary artery disease.
4. An oncologist accesses the evicore system to guide their decision on the appropriate chemotherapy regimen for a patient with a specific type of cancer.
5. A gastroenterologist uses evicore to determine the appropriate screening interval for a patient with a history of colon polyps.