How To Use HCPCS Code G1004

HCPCS code G1004 describes a clinical decision support mechanism provided by a national decision support company, as defined by the Medicare Appropriate Use Criteria (AUC) program. This code is used to identify and bill for the use of a clinical decision support tool that assists healthcare providers in making appropriate and evidence-based decisions regarding the ordering of certain medical services or procedures.

1. What is HCPCS G1004?

HCPCS code G1004 is a specific code used to identify the use of a clinical decision support mechanism provided by a national decision support company. This code is part of the Healthcare Common Procedure Coding System (HCPCS) and is used to facilitate accurate billing and reimbursement for the use of this specific tool.

2. Official Description

The official description of HCPCS code G1004 is “Clinical decision support mechanism national decision support company, as defined by the Medicare appropriate use criteria program.” The short description for this code is “Cdsm ndsc.”

3. Procedure

1. The healthcare provider accesses the clinical decision support mechanism provided by a national decision support company.
2. The provider inputs relevant patient information, such as medical history, symptoms, and diagnostic test results, into the decision support tool.
3. The tool analyzes the inputted data and provides evidence-based recommendations or guidelines for the appropriate use of certain medical services or procedures.
4. The provider reviews the recommendations and uses them to inform their decision-making process regarding the ordering of the recommended services or procedures.
5. The provider documents the use of the clinical decision support mechanism in the patient’s medical record.

4. When to use HCPCS code G1004

HCPCS code G1004 should be used when a healthcare provider utilizes a clinical decision support mechanism provided by a national decision support company. This code is specifically used to identify and bill for the use of this tool in the context of the Medicare Appropriate Use Criteria (AUC) program.

5. Billing Guidelines and Documentation Requirements

When billing for the use of HCPCS code G1004, healthcare providers should ensure that the following documentation requirements are met:

• Documentation of the patient’s medical history, symptoms, and diagnostic test results that were used as input for the clinical decision support mechanism.
• Documentation of the recommendations or guidelines provided by the decision support tool.
• Documentation of the provider’s review and consideration of the recommendations in their decision-making process.
• Documentation of the use of the clinical decision support mechanism in the patient’s medical record.

6. Historical Information and Code Maintenance

HCPCS code G1004 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.

7. Medicare and Insurance Coverage

Medicare and other insurance providers may cover the use of HCPCS code G1004, but the specific coverage and reimbursement policies 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 or not covered by Medicare. The multiple pricing indicator code is 9, which indicates that the value for this code is not established. It is important for healthcare providers to verify the coverage and reimbursement policies of the specific insurance plans they work with.

8. Examples

Here are five examples of scenarios in which HCPCS code G1004 may be used:

1. A primary care physician uses a clinical decision support mechanism to determine the appropriateness of ordering a specific imaging test for a patient with lower back pain.
2. An orthopedic surgeon utilizes a decision support tool to guide their decision-making process regarding the need for surgical intervention in a patient with a suspected musculoskeletal condition.
3. A cardiologist accesses a clinical decision support mechanism to evaluate the appropriateness of ordering a cardiac stress test for a patient with chest pain.
4. An oncologist uses a decision support tool to determine the most appropriate chemotherapy regimen for a patient with a specific type of cancer.
5. A radiologist utilizes a clinical decision support mechanism to assess the need for additional imaging studies in a patient with an abnormal finding on a previous scan.