How To Use HCPCS Code G9400

HCPCS code G9400 describes the documentation of medical or patient reasons for not discussing treatment options. This code is used when there are specific medical or patient-related factors that prevent the healthcare provider from engaging in a discussion about treatment options with the patient. It is important for medical coders to understand the usage and guidelines for this code to ensure accurate billing and reimbursement.

1. What is HCPCS G9400?

HCPCS code G9400 is used to indicate that the healthcare provider has documented the medical or patient reasons for not discussing treatment options. This code is specific to situations where the patient is not a candidate for treatment due to advanced physical or mental health comorbidity, including active substance use. It also includes scenarios where the patient is currently receiving antiviral treatment, has successfully completed antiviral treatment prior to the reporting period, or has other documented medical reasons. Additionally, patient reasons for not participating in the discussion are also included, such as the patient being unable or unwilling to engage in the conversation.

2. Official Description

The official description of HCPCS code G9400 is “Documentation of medical or patient reason(s) for not discussing treatment options; medical reasons: patient is not a candidate for treatment due to advanced physical or mental health comorbidity (including active substance use); currently receiving antiviral treatment; successful antiviral treatment (with sustained virologic response) prior to reporting period; other documented medical reasons; patient reasons: patient unable or unwilling to participate in the discussion or other patient reasons.” The short description for this code is “Doc reas no disc tx opt.”

3. Procedure

1. The healthcare provider should thoroughly document the specific medical or patient reasons for not discussing treatment options.
2. For medical reasons, the provider should clearly state the advanced physical or mental health comorbidity, including active substance use, that makes the patient ineligible for treatment.
3. If the patient is currently receiving antiviral treatment, the provider should note this in the documentation.
4. If the patient has successfully completed antiviral treatment with a sustained virologic response prior to the reporting period, this should be documented.
5. Other documented medical reasons that make the patient ineligible for treatment should be clearly stated.
6. If the patient is unable or unwilling to participate in the discussion about treatment options, the provider should document the reasons for this.

4. When to use HCPCS code G9400

HCPCS code G9400 should be used when the healthcare provider has documented the medical or patient reasons for not discussing treatment options. It is important to ensure that the specific eligibility criteria or guidelines for using this code are met before assigning it to a patient’s record. The documentation should clearly indicate the reasons why treatment options were not discussed, whether it is due to medical factors or patient-related factors.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9400, healthcare providers need to ensure that the documentation supports the medical or patient reasons for not discussing treatment options. The documentation should be detailed and specific, clearly stating the factors that make the patient ineligible for treatment or unable/unwilling to participate in the discussion. It is important to follow the billing guidelines provided by the payer to ensure accurate reimbursement for the services rendered.

6. Historical Information and Code Maintenance

HCPCS code G9400 was added to the Healthcare Common Procedure Coding System on January 01, 2015. It has an effective date of January 01, 2022. As of December 31, 2021, this code has been terminated. 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

HCPCS code G9400 is subject to carrier judgment when it comes to Medicare coverage. The pricing indicator code for this code is 00, which means the service is not separately priced by Part B. This could be due to the service not being covered, bundled, or used by Part A only. The multiple pricing indicator code is 9, which indicates that it is not applicable as HCPCS G9400 is not priced separately by Part B or the value is not established. It is important to check with the specific insurance provider for coverage and reimbursement details.

8. Examples

Here are five examples of when HCPCS code G9400 should be billed:

1. A patient with advanced physical comorbidity due to a chronic illness is not eligible for a specific treatment option. The healthcare provider documents this medical reason for not discussing treatment options.
2. A patient with a history of substance use disorder is currently receiving antiviral treatment, making them ineligible for other treatment options. The provider documents this medical reason for not discussing alternative treatments.
3. A patient successfully completed antiviral treatment with a sustained virologic response prior to the reporting period. The provider documents this as a medical reason for not discussing further treatment options.
4. A patient is unable to participate in the discussion about treatment options due to a mental health condition. The provider documents this patient reason for not discussing treatment options.
5. A patient is unwilling to engage in the conversation about treatment options. The provider documents this patient reason for not discussing treatment options.