How To Use HCPCS Code G9198

HCPCS code G9198 describes the situation where an order for first or second generation cephalosporin for antimicrobial prophylaxis was not documented, and the reason for not documenting the order is not given. This code is terminated as of December 31, 2022. Let’s explore the details of HCPCS code G9198 and understand its usage and implications.

1. What is HCPCS G9198?

HCPCS code G9198 is used to identify the absence of an order for first or second generation cephalosporin for antimicrobial prophylaxis, without any given reason for not documenting the order. This code is specific to situations where the provider fails to document the order for this particular medication. It helps in capturing instances where the necessary prophylactic treatment was not prescribed or recorded.

2. Official Description

The official description of HCPCS code G9198 is “Order for first or second generation cephalosporin for antimicrobial prophylaxis was not documented, reason not given.” The short description for this code is “No order for ceph no reason.”

3. Procedure

1. The healthcare provider should review the patient’s medical history and assess the need for antimicrobial prophylaxis.
2. If it is determined that prophylaxis with a first or second generation cephalosporin is necessary, the provider should document the order in the patient’s medical record.
3. The order should include the specific medication, dosage, frequency, and duration of the prophylactic treatment.
4. If the provider fails to document the order for the cephalosporin or does not provide a reason for not documenting it, HCPCS code G9198 should be used.

4. When to use HCPCS code G9198

HCPCS code G9198 should be used when there is no documented order for first or second generation cephalosporin for antimicrobial prophylaxis, and no reason is given for not documenting the order. It is important to note that this code is specific to the absence of the order and does not cover situations where the order was documented but not followed.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9198, healthcare providers need to ensure that the absence of the order for first or second generation cephalosporin for antimicrobial prophylaxis is clearly documented in the patient’s medical record. The documentation should include the reason for not documenting the order, if available. This information is crucial for accurate coding and billing.

6. Historical Information and Code Maintenance

HCPCS code G9198 was added to the Healthcare Common Procedure Coding System on January 01, 2014. It has an effective date of January 01, 2023, indicating that it will no longer be valid for use after December 31, 2022. The code has a pricing indicator code of 00, which means it is not separately priced by Part B. Additionally, the multiple pricing indicator code is 9, indicating that the value for this code is not established.

7. Medicare and Insurance Coverage

Medicare coverage for HCPCS code G9198 is determined by carrier judgment, denoted by the coverage code C. It is important to consult the Medicare guidelines and policies to understand the specific reimbursement rules and requirements for this code. Other insurance providers may have their own coverage policies, so it is essential to verify the coverage and reimbursement guidelines with each individual insurer.

8. Examples

Here are five examples illustrating when HCPCS code G9198 should be billed:

1. A patient undergoes a surgical procedure that requires antimicrobial prophylaxis, but the healthcare provider fails to document the order for the first or second generation cephalosporin.
2. A patient with a history of allergic reactions to cephalosporins is scheduled for a procedure that necessitates antimicrobial prophylaxis. However, the provider does not document the order for an alternative medication or provide a reason for not documenting it.
3. A patient is admitted to the hospital for a procedure that requires antimicrobial prophylaxis, but the provider overlooks documenting the order for the cephalosporin.
4. A patient is prescribed a medication regimen that includes a first or second generation cephalosporin for antimicrobial prophylaxis, but the provider fails to document the order in the patient’s medical record.
5. A patient undergoes a surgical procedure, and although the provider documents the order for antimicrobial prophylaxis, they do not specify the medication as a first or second generation cephalosporin.