How To Use HCPCS Code G8928

HCPCS code G8928 describes the use of adjuvant chemotherapy that is not prescribed or previously received, for documented reasons. This code is used to indicate specific circumstances where adjuvant chemotherapy is not recommended or appropriate for a patient. In this article, we will explore the details of HCPCS code G8928, 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 G8928?

HCPCS code G8928 is used to identify cases where adjuvant chemotherapy is not prescribed or previously received for documented reasons. It signifies that there are specific factors or conditions that prevent the use of adjuvant chemotherapy for a patient. These reasons may include medical co-morbidities, diagnosis date more than 5 years prior to the current visit date, patient’s diagnosis date is within 120 days of the end of the 12 month reporting period, patient’s cancer has metastasized, medical contraindication/allergy, poor performance status, other medical reasons, patient refusal, patient is currently enrolled in a clinical trial that precludes prescription of chemotherapy, or other system reasons.

2. Official Description

The official description of HCPCS code G8928 is “Adjuvant chemotherapy not prescribed or previously received, for documented reasons (e.g., medical co-morbidities, diagnosis date more than 5 years prior to the current visit date, patient’s diagnosis date is within 120 days of the end of the 12 month reporting period, patient’s cancer has metastasized, medical contraindication/allergy, poor performance status, other medical reasons, patient refusal, other patient reasons, patient is currently enrolled in a clinical trial that precludes prescription of chemotherapy, other system reasons)”. The short description for this code is “Adj chem not pres rsn spec”.

3. Procedure

1. The provider should thoroughly assess the patient’s medical history, including any co-morbidities, performance status, and previous cancer diagnosis and treatment.
2. If the patient meets any of the documented reasons for not prescribing or previously receiving adjuvant chemotherapy, the provider should clearly document these reasons in the patient’s medical record.
3. The provider should discuss alternative treatment options with the patient, taking into consideration the specific circumstances that prevent the use of adjuvant chemotherapy.
4. Any decisions made regarding the use of adjuvant chemotherapy should be well-documented in the patient’s medical record, including the rationale behind the decision.

4. When to use HCPCS code G8928

HCPCS code G8928 should be used when the documented reasons for not prescribing or previously receiving adjuvant chemotherapy are present. These reasons may include medical co-morbidities, diagnosis date more than 5 years prior to the current visit date, patient’s diagnosis date is within 120 days of the end of the 12 month reporting period, patient’s cancer has metastasized, medical contraindication/allergy, poor performance status, other medical reasons, patient refusal, patient is currently enrolled in a clinical trial that precludes prescription of chemotherapy, or other system reasons. It is important to accurately code and document these reasons to ensure proper reimbursement and to provide a comprehensive medical record.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G8928, healthcare providers should ensure that the documented reasons for not prescribing or previously receiving adjuvant chemotherapy are clearly stated in the patient’s medical record. This documentation should include detailed information about the specific circumstances that prevent the use of adjuvant chemotherapy, such as medical co-morbidities, diagnosis dates, metastasis, contraindications/allergies, poor performance status, patient refusal, clinical trial enrollment, or other system reasons. Accurate and thorough documentation is essential for proper billing and reimbursement.

6. Historical Information and Code Maintenance

HCPCS code G8928 was added to the Healthcare Common Procedure Coding System on January 01, 2013. It has a termination date of December 31, 2016. This code has a pricing indicator code of 00, which means it is not separately priced by Part B. The multiple pricing indicator code is 9, indicating that it is not applicable as HCPCS G8928 is not priced separately by Part B or the value is not established. The type of service code for this code is 1, indicating medical care. It is important to stay updated on any changes or revisions to HCPCS code G8928 to ensure accurate coding and billing.

7. Medicare and Insurance Coverage

HCPCS code G8928 is covered by Medicare, with the coverage code being C, which signifies carrier judgment. However, it is important to verify coverage and reimbursement policies with individual insurance providers, as coverage may vary. The pricing indicator code of 00 indicates that this service is not separately priced by Part B and may be bundled or not covered. Providers should review the specific guidelines and policies of Medicare and other insurance companies to determine the appropriate billing and reimbursement processes for HCPCS code G8928.

8. Examples

Here are five examples of when HCPCS code G8928 should be billed:

1. A patient with significant medical co-morbidities that contraindicate the use of adjuvant chemotherapy.
2. A patient whose cancer diagnosis date is more than 5 years prior to the current visit date.
3. A patient whose cancer has metastasized, making adjuvant chemotherapy ineffective.
4. A patient with a documented medical contraindication or allergy to chemotherapy drugs.
5. A patient with a poor performance status, indicating that they would not tolerate adjuvant chemotherapy well.