How To Use HCPCS Code G9938

HCPCS code G9938 describes the eligibility criteria for patients aged 66 or older who are enrolled in institutional special needs plans (SNP) or residing in long-term care facilities. This code is used to identify patients who have been in a long-term care facility for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period.

1. What is HCPCS G9938?

HCPCS code G9938 is a specific code used in medical coding to identify patients aged 66 or older who are enrolled in institutional special needs plans (SNP) or residing in long-term care facilities. This code is used to determine the eligibility of patients who have been in a long-term care facility for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period.

2. Official Description

The official description of HCPCS code G9938 is “Patients aged 66 or older in institutional special needs plans (SNP) or residing in long-term care with pos code 32, 33, 34, 54, or 56 for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period.” The short description of this code is “Pt 66+ SNP or LTC POS > 90d.”

3. Procedure

1. Patients aged 66 or older who are enrolled in institutional special needs plans (SNP) or residing in long-term care facilities are eligible for HCPCS code G9938.
2. The patient must have been in a long-term care facility for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period.
3. The provider must verify the patient’s age and enrollment in an institutional special needs plan or residency in a long-term care facility.
4. The provider should document the patient’s eligibility criteria and use HCPCS code G9938 for billing purposes.

4. When to use HCPCS code G9938

HCPCS code G9938 should be used when a patient aged 66 or older meets the eligibility criteria of being enrolled in an institutional special needs plan (SNP) or residing in a long-term care facility. The patient must have been in the long-term care facility for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period.

5. Billing Guidelines and Documentation Requirements

When using HCPCS code G9938, healthcare providers need to document the patient’s age, enrollment in an institutional special needs plan (SNP), or residency in a long-term care facility. This documentation is crucial for accurate billing and reimbursement. Providers should ensure that the patient’s medical records clearly indicate the patient’s eligibility criteria for using HCPCS code G9938.

6. Historical Information and Code Maintenance

HCPCS code G9938 was added to the Healthcare Common Procedure Coding System on January 01, 2018. It has an action effective date of January 01, 2024. As of now, there have been no maintenance actions taken for this code, as indicated by the action code C, which means a change in the long description of the procedure or modifier code.

7. Medicare and Insurance Coverage

HCPCS code G9938 is covered by Medicare and other insurance providers. The pricing indicator code for this code is 00, which means the service is not separately priced by Part B. This indicates that the service is bundled or not covered by Part B. The multiple pricing indicator code is 9, which means it is not applicable as HCPCS code G9938 is not priced separately by Part B or the value is not established.

8. Examples

Here are five examples of when HCPCS code G9938 should be billed:

1. An 80-year-old patient who has been residing in a long-term care facility for 120 consecutive days.
2. A 70-year-old patient who is enrolled in an institutional special needs plan (SNP) and has been in a long-term care facility for 100 consecutive days.
3. A 75-year-old patient who has been residing in a long-term care facility for 150 consecutive days.
4. An 85-year-old patient who is enrolled in an institutional special needs plan (SNP) and has been in a long-term care facility for 200 consecutive days.
5. A 90-year-old patient who has been residing in a long-term care facility for 180 consecutive days.