How To Use HCPCS Code G9196

HCPCS code G9196 describes the documentation of medical reasons for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis. This code is used to indicate that there are specific medical reasons why a healthcare provider did not prescribe a cephalosporin antibiotic for a patient, despite it being a common practice for surgical procedures.

1. What is HCPCS G9196?

HCPCS code G9196 is a specific code used in medical coding to identify and document the medical reasons for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis. It is important for healthcare providers to accurately document these reasons to ensure proper coding and billing.

2. Official Description

The official description of HCPCS code G9196 is “Documentation of medical reason(s) for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis (e.g., patients enrolled in clinical trials, patients with documented infection prior to surgical procedure of interest, patients who were receiving antibiotics more than 24 hours prior to surgery [except colon surgery patients taking oral prophylactic antibiotics], patients who were receiving antibiotics within 24 hours prior to arrival [except colon surgery patients taking oral prophylactic antibiotics], other medical reason(s)).” The short description is “Med reason for no ceph.”

3. Procedure

1. When documenting medical reasons for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis, healthcare providers should clearly state the specific reason(s) for their decision.
2. Examples of medical reasons that can be documented include patients enrolled in clinical trials, patients with documented infection prior to the surgical procedure, patients who were already receiving antibiotics more than 24 hours prior to surgery (except colon surgery patients taking oral prophylactic antibiotics), patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics), and any other relevant medical reasons.
3. It is important for healthcare providers to provide detailed and accurate documentation to support the use of HCPCS code G9196.

4. When to use HCPCS code G9196

HCPCS code G9196 should be used when there are specific medical reasons for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis. These reasons may include patients enrolled in clinical trials, patients with documented infection prior to the surgical procedure, patients who were already receiving antibiotics more than 24 hours prior to surgery (except colon surgery patients taking oral prophylactic antibiotics), patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics), and any other relevant medical reasons.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9196, healthcare providers should ensure that they have documented the specific medical reasons for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis. This documentation should be clear, detailed, and support the medical necessity of the decision.

6. Historical Information and Code Maintenance

HCPCS code G9196 was added to the Healthcare Common Procedure Coding System on January 1, 2014. It has a termination date of December 31, 2022. The code has a coverage code of C, which indicates that carrier judgment is used for coverage decisions. The action code for this code is N, which means that there is no maintenance for this code. The code has a pricing indicator code of 00, indicating that the service is not separately priced by Part B. The multiple pricing indicator code is 9, which means that the code is not applicable for separate pricing by Part B.

7. Medicare and Insurance Coverage

Medicare and other insurance coverage for HCPCS code G9196 may vary. It is important for healthcare providers to check with the specific payer for coverage and reimbursement guidelines. The pricing indicator code of 00 indicates that the service is not separately priced by Part B, and the multiple pricing indicator code of 9 indicates that the code is not applicable for separate pricing by Part B.

8. Examples

Here are five examples of when HCPCS code G9196 should be billed:

1. A patient enrolled in a clinical trial where the use of cephalosporin for antimicrobial prophylaxis is contraindicated.
2. A patient with a documented infection prior to the surgical procedure, requiring an alternative antimicrobial prophylaxis.
3. A patient who has been receiving antibiotics for more than 24 hours prior to surgery, except for colon surgery patients taking oral prophylactic antibiotics.
4. A patient who has been receiving antibiotics within 24 hours prior to arrival, except for colon surgery patients taking oral prophylactic antibiotics.
5. A patient with other documented medical reasons for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis.