How To Use HCPCS Code G9940

HCPCS code G9940 describes the documentation of medical reasons for not being on a statin therapy. This code is used to indicate that the healthcare provider has documented the specific medical reasons for not prescribing a statin medication to 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 G9940?

HCPCS code G9940 is a specific code used in medical coding to indicate the documentation of medical reasons for not being on a statin therapy. It is important for healthcare providers to document the specific reasons why a patient is not prescribed a statin medication, such as pregnancy, in vitro fertilization, clomiphene rx, end-stage renal disease (ESRD), cirrhosis, or muscular pain and disease during the measurement period or prior year.

2. Official Description

The official description of HCPCS code G9940 is “Documentation of medical reason(s) for not on a statin (e.g., pregnancy, in vitro fertilization, clomiphene rx, esrd, cirrhosis, muscular pain and disease during the measurement period or prior year)”. The short description for this code is “Doc reas no statin therapy”.

3. Procedure

1. The healthcare provider should thoroughly review the patient’s medical history and current condition to determine if a statin therapy is appropriate.
2. If the provider determines that a statin therapy is not suitable for the patient due to specific medical reasons, they should document these reasons in the patient’s medical record.
3. The documentation should clearly state the medical reasons for not prescribing a statin medication, such as pregnancy, in vitro fertilization, clomiphene rx, ESRD, cirrhosis, or muscular pain and disease during the measurement period or prior year.
4. The documentation should be detailed and specific, providing sufficient information to support the decision to not prescribe a statin therapy.

4. When to use HCPCS code G9940

HCPCS code G9940 should be used when the healthcare provider has documented the medical reasons for not prescribing a statin therapy to the patient. It is important to use this code when submitting claims for reimbursement to accurately reflect the decision made by the provider.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9940, healthcare providers need to ensure that the documentation in the patient’s medical record clearly supports the medical reasons for not prescribing a statin therapy. The documentation should be detailed and specific, providing sufficient information to justify the decision. It is important to include the specific medical reasons, such as pregnancy, in vitro fertilization, clomiphene rx, ESRD, cirrhosis, or muscular pain and disease during the measurement period or prior year.

6. Historical Information and Code Maintenance

HCPCS code G9940 was added to the Healthcare Common Procedure Coding System on January 01, 2018. There have been no maintenance actions taken for this code, as indicated by the action code N, which means no maintenance for this code. The pricing indicator code for this code is 00, which means that the service is not separately priced by Part B. The multiple pricing indicator code is 9, indicating that it is not applicable as HCPCS G9940 is not priced separately by Part B.

7. Medicare and Insurance Coverage

Medicare coverage for HCPCS code G9940 may vary depending on the specific circumstances and guidelines set by Medicare. It is important to review the Medicare guidelines and policies to determine if this code is payable. The pricing indicator code 00 indicates that the service is not separately priced by Part B, and the multiple pricing indicator code 9 indicates that it is not applicable as HCPCS G9940 is not priced separately by Part B.

8. Examples

Here are five examples of when HCPCS code G9940 should be billed:

1. A pregnant patient who is not prescribed a statin therapy due to the potential risks to the fetus.
2. A patient undergoing in vitro fertilization who is advised not to take a statin medication during the treatment process.
3. A patient with a history of clomiphene rx who is not recommended to take a statin medication.
4. A patient with end-stage renal disease (ESRD) who is not prescribed a statin therapy due to the specific medical condition.
5. A patient with cirrhosis who is advised against taking a statin medication due to the potential impact on liver function.