How To Use HCPCS Code G9616

HCPCS code G9616 describes the documentation of reason(s) for not documenting a preoperative assessment in cases where a gynecologic or other pelvic malignancy is noted at the time of surgery. This code is used to indicate that the healthcare provider did not perform a preoperative assessment due to the presence of a pelvic malignancy.

1. What is HCPCS G9616?

HCPCS code G9616 is a specific code used in medical coding to identify the documentation of reason(s) for not documenting a preoperative assessment in cases where a gynecologic or other pelvic malignancy is noted at the time of surgery. It is important for medical coders to accurately assign this code to ensure proper reimbursement and tracking of healthcare services.

2. Official Description

The official description of HCPCS code G9616 is “Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient with a gynecologic or other pelvic malignancy noted at the time of surgery)”. The short description for this code is “Doc rsn no preop assmt”. These descriptions provide a clear understanding of the purpose and usage of this specific code.

3. Procedure

  1. When a patient with a gynecologic or other pelvic malignancy is scheduled for surgery, the healthcare provider should document the reason(s) for not performing a preoperative assessment.
  2. This documentation should include detailed information about the patient’s condition, such as the type of malignancy and any specific factors that influenced the decision to forgo the preoperative assessment.
  3. The healthcare provider should ensure that the documentation is accurate, complete, and supports the medical necessity of not performing a preoperative assessment.
  4. It is important to note that this code is only applicable in cases where a gynecologic or other pelvic malignancy is noted at the time of surgery.

4. When to use HCPCS code G9616

HCPCS code G9616 should be used when a healthcare provider encounters a patient with a gynecologic or other pelvic malignancy at the time of surgery and decides not to perform a preoperative assessment. This code indicates that the provider has documented the reason(s) for not conducting the assessment due to the presence of the malignancy.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9616, healthcare providers need to ensure that the documentation clearly supports the reason(s) for not performing a preoperative assessment. The documentation should include details about the patient’s pelvic malignancy and any specific factors that influenced the decision. It is important to accurately code and document the services provided to ensure proper reimbursement.

6. Historical Information and Code Maintenance

HCPCS code G9616 was added to the Healthcare Common Procedure Coding System on January 01, 2016. It has an effective date of January 01, 2021, and was terminated on December 31, 2020. The termination of this code indicates that it is no longer in use and should not be assigned for services provided after December 31, 2020.

7. Medicare and Insurance Coverage

Medicare and other insurance providers may have specific coverage policies for HCPCS code G9616. It is important for healthcare providers to review the coverage guidelines of each payer to determine if this code is payable. The pricing indicator code for this code is 00, which indicates that the service is not separately priced by Part B. The multiple pricing indicator code is 9, which means that the value for this code is not established.

8. Examples

Here are five examples of when HCPCS code G9616 should be billed:

  1. A patient with a gynecologic malignancy undergoes surgery, and the healthcare provider documents the reason for not performing a preoperative assessment due to the presence of the malignancy.
  2. A patient with a pelvic malignancy is scheduled for surgery, and the healthcare provider determines that a preoperative assessment is not necessary based on the patient’s medical history and current condition.
  3. A patient with a known gynecologic malignancy presents for surgery, and the healthcare provider decides not to perform a preoperative assessment due to the advanced stage of the malignancy.
  4. A patient with a pelvic malignancy is admitted for surgery, and the healthcare provider documents the reason for not conducting a preoperative assessment due to the urgent nature of the procedure.
  5. A patient with a gynecologic malignancy undergoes emergency surgery, and the healthcare provider determines that a preoperative assessment is not feasible given the time constraints.

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