How To Use HCPCS Code G9513

HCPCS code G9513 describes an individual who did not have a predictive modeling (PDC) score of 0.8 or greater. This code is used to indicate that the individual’s PDC score, which measures medication adherence, did not meet the threshold of 0.8 or higher. In this article, we will explore the official description of HCPCS code G9513, its procedure, when to use it, billing guidelines and documentation requirements, historical information and code maintenance, Medicare and insurance coverage, and provide examples of when this code should be billed.

1. What is HCPCS G9513?

HCPCS code G9513 is used to identify an individual who did not have a PDC score of 0.8 or greater. The PDC score is a measure of medication adherence, indicating how well a patient follows their prescribed medication regimen. A PDC score of 0.8 or higher suggests good adherence, while a score below 0.8 indicates poor adherence. This code is used to capture instances where the individual’s PDC score falls below the threshold.

2. Official Description

The official description of HCPCS code G9513 is “Individual did not have a pdc of 0.8 or greater.” The short description is “Indiv pdc not > 0.8.” This description clearly states that the code is used to indicate that the individual’s PDC score did not meet the threshold of 0.8 or higher.

3. Procedure

1. The provider assesses the individual’s medication adherence by calculating their PDC score.
2. If the PDC score is less than 0.8, the provider assigns HCPCS code G9513 to indicate the individual’s poor medication adherence.

4. When to use HCPCS code G9513

HCPCS code G9513 should be used when an individual’s PDC score is below 0.8. This code is applicable in situations where the provider wants to document and report the individual’s poor medication adherence. It is important to accurately capture this information to ensure appropriate care coordination and intervention.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9513, healthcare providers need to document the individual’s PDC score and clearly indicate that it is below 0.8. This documentation should be included in the medical record to support the use of this code. Additionally, providers should ensure that the code is billed correctly according to the guidelines set forth by the payer.

6. Historical Information and Code Maintenance

HCPCS code G9513 was added to the Healthcare Common Procedure Coding System on January 01, 2016. Since its addition, there have been no maintenance actions taken for this code, as indicated by the action code N, which means no maintenance for this code. This code has remained unchanged since its inception.

7. Medicare and Insurance Coverage

Medicare and other insurance coverage for HCPCS code G9513 may vary. The pricing indicator code for this code is 00, which means that the service is not separately priced by Part B. This indicates that the service may not be covered or may be bundled with other services. The multiple pricing indicator code is 9, which means that the value for this code is not established. It is important to check with the specific payer to determine coverage and reimbursement for this code.

8. Examples

Here are five examples of when HCPCS code G9513 should be billed:

1. An individual with a PDC score of 0.6, indicating poor medication adherence.
2. A patient whose PDC score is 0.7, falling below the threshold of 0.8.
3. An individual who consistently misses medication doses, resulting in a PDC score of 0.5.
4. A patient who frequently forgets to refill their prescriptions, leading to a PDC score of 0.7.
5. An individual who intentionally stops taking their medication, resulting in a PDC score of 0.3.