How To Use HCPCS Code G1011

HCPCS code G1011 describes a clinical decision support mechanism that is a qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria (AUC) program. This code is used to identify the use of a specific tool that assists healthcare providers in making clinical decisions based on evidence-based guidelines and best practices.

1. What is HCPCS G1011?

HCPCS code G1011 is a specific code that represents a clinical decision support mechanism. It is used to identify the use of a qualified tool that helps healthcare providers in making informed decisions about patient care. This code is not specific to any particular tool, but rather encompasses any qualified tool that meets the requirements set forth by the Medicare AUC program.

2. Official Description

The official description of HCPCS code G1011 is “Clinical decision support mechanism, qualified tool not otherwise specified, as defined by the Medicare Appropriate Use Criteria (AUC) program.” The short description for this code is “Cdsm qualified nos.”

3. Procedure

1. When using HCPCS code G1011, the healthcare provider must ensure that they are utilizing a clinical decision support mechanism that meets the qualifications set forth by the Medicare AUC program.
2. The provider should follow the specific guidelines and requirements outlined by the AUC program for the use of the qualified tool.
3. The clinical decision support mechanism should be used during the decision-making process to assist the provider in making appropriate and evidence-based clinical decisions.
4. Documentation should be maintained to support the use of the clinical decision support mechanism and its impact on the patient’s care.

4. When to use HCPCS code G1011

HCPCS code G1011 should be used when a healthcare provider utilizes a qualified clinical decision support mechanism as defined by the Medicare AUC program. This code is used to indicate that a qualified tool was used to assist in making clinical decisions for the patient’s care.

5. Billing Guidelines and Documentation Requirements

When billing for the use of HCPCS code G1011, healthcare providers should ensure that they have documented the use of the qualified clinical decision support mechanism in the patient’s medical record. This documentation should include the specific tool used, the date and time of its use, and any relevant information regarding the impact of the tool on the patient’s care.

6. Historical Information and Code Maintenance

HCPCS code G1011 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 coverage for HCPCS code G1011 is determined by carrier judgment, as indicated by the coverage code C. This means that Medicare will make a determination on whether to cover the use of a qualified clinical decision support mechanism on a case-by-case basis.

8. Examples

Here are five examples of when HCPCS code G1011 should be billed:

1. A primary care physician uses a qualified clinical decision support mechanism to determine the appropriate diagnostic tests for a patient with suspected cardiovascular disease.
2. An oncologist utilizes a qualified tool to guide treatment decisions for a patient with advanced lung cancer.
3. A psychiatrist uses a clinical decision support mechanism to assist in the diagnosis and treatment planning for a patient with a complex mental health condition.
4. An orthopedic surgeon utilizes a qualified tool to guide the selection of the most appropriate surgical procedure for a patient with a musculoskeletal injury.
5. A pediatrician uses a clinical decision support mechanism to determine the appropriate immunization schedule for a child based on their age and medical history.