How To Use HCPCS Code G9220

HCPCS code G9220 describes the situation where pneumocystis jiroveci pneumonia (PJP) prophylaxis is not prescribed within 3 months of a low CD4+ cell count below 500 cells/mm3 or a CD4 percentage below 15% for medical reasons. This code indicates that the patient’s CD4+ cell count has returned to an acceptable range within 3 months after falling below the threshold, indicating that the patient does not require PJP prophylaxis.

1. What is HCPCS G9220?

HCPCS code G9220 is used to identify the specific scenario where PJP prophylaxis is not prescribed within 3 months of a low CD4+ cell count or CD4 percentage for medical reasons. It helps medical coders and healthcare providers accurately document and bill for this particular situation.

2. Official Description

The official description of HCPCS code G9220 is “Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low CD4+ cell count below 500 cells/mm3 or a CD4 percentage below 15% for medical reason (i.e., patient’s CD4+ cell count above threshold within 3 months after CD4+ cell count below threshold, indicating that the patient’s CD4+ levels are within an acceptable range and the patient does not require PJP prophylaxis).” The short description is “No order for PJP for medical reason.”

3. Procedure

1. When encountering a patient with a low CD4+ cell count below 500 cells/mm3 or a CD4 percentage below 15%, the healthcare provider should assess the medical reasons for this condition.
2. If the patient’s CD4+ cell count returns to an acceptable range within 3 months after falling below the threshold, indicating that the patient’s CD4+ levels are within an acceptable range, PJP prophylaxis is not required.
3. The healthcare provider should document the medical reasons for not prescribing PJP prophylaxis within the specified timeframe.

4. When to use HCPCS code G9220

HCPCS code G9220 should be used when the patient’s CD4+ cell count or CD4 percentage falls below the specified thresholds, and within 3 months, the CD4+ cell count returns to an acceptable range. This code signifies that PJP prophylaxis is not necessary due to the patient’s improved CD4+ levels.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9220, healthcare providers need to document the patient’s CD4+ cell count or CD4 percentage, the timeframe in which it fell below the threshold, and the subsequent improvement within 3 months. This documentation is crucial for accurate billing and reimbursement.

6. Historical Information and Code Maintenance

HCPCS code G9220 was added to the Healthcare Common Procedure Coding System on January 1, 2014. It has an effective date of January 1, 2015. This code was terminated on December 31, 2014, indicating that it is no longer in use. No maintenance actions have been 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 coverage for HCPCS code G9220 may vary. It is important to consult the specific guidelines and policies of the respective payers to determine coverage and reimbursement. The pricing indicator code for this code is 00, which means the service is not separately priced by Part B. The multiple pricing indicator code is 9, indicating that it is not applicable as HCPCS is not priced separately by Part B or the value is not established.

8. Examples

Here are five examples of when HCPCS code G9220 should be billed:

1. A patient’s CD4+ cell count falls below 500 cells/mm3, but within 3 months, it returns to an acceptable range, and PJP prophylaxis is not prescribed due to the improved CD4+ levels.
2. A patient’s CD4 percentage drops below 15%, but within 3 months, it increases to a level above the threshold, indicating that PJP prophylaxis is not necessary.
3. After a low CD4+ cell count or CD4 percentage, the patient’s levels improve within 3 months, and the healthcare provider determines that PJP prophylaxis is not required for medical reasons.
4. A patient’s CD4+ cell count falls below 500 cells/mm3, but subsequent tests show that the levels have returned to an acceptable range within the specified timeframe, indicating that PJP prophylaxis is not needed.
5. Within 3 months of a low CD4 percentage, the patient’s levels improve, and the healthcare provider determines that PJP prophylaxis is not necessary based on the improved CD4 levels.