How To Use HCPCS Code G9968

HCPCS code G9968 describes the situation where a patient has been referred to another clinician or specialist during the measurement period. This code is used to indicate that the patient was sent to a different provider or specialist for further evaluation or treatment.

1. What is HCPCS G9968?

HCPCS code G9968 is a specific code used in medical coding to identify the referral of a patient to another clinician or specialist. It signifies that the patient has been directed to seek additional care or expertise beyond the primary care provider.

2. Official Description

The official description of HCPCS code G9968 is “Patient was referred to another clinician or specialist during the measurement period.” This description clearly states the purpose of the code, indicating that the patient has been referred to another healthcare professional for further evaluation or treatment.

3. Procedure

1. The referring provider assesses the patient’s condition and determines that additional expertise or specialized care is required.
2. The referring provider identifies a suitable clinician or specialist to whom the patient can be referred.
3. The referring provider communicates the referral to the patient, providing necessary information about the receiving clinician or specialist.
4. The patient contacts the referred clinician or specialist to schedule an appointment.
5. The receiving clinician or specialist evaluates the patient and provides the necessary care or treatment.

4. When to use HCPCS code G9968

HCPCS code G9968 should be used when a patient has been referred to another clinician or specialist during the measurement period. This code is applicable when the referring provider determines that the patient’s condition requires the expertise or specialized care of another healthcare professional.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G9968, healthcare providers need to document the referral process and include the necessary information in the patient’s medical record. This documentation should include the reason for the referral, the name and contact information of the receiving clinician or specialist, and any relevant clinical information that supports the need for the referral.

6. Historical Information and Code Maintenance

HCPCS code G9968 was added to the Healthcare Common Procedure Coding System on January 01, 2018. As of January 01, 2023, 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

The coverage of HCPCS code G9968 may vary depending on the specific insurance plan. It is important for healthcare providers to check with the patient’s insurance carrier to determine if this code is payable. 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 be bundled or not covered by Medicare or other insurers.

8. Examples

Here are five examples of when HCPCS code G9968 should be billed:

1. A primary care physician refers a patient with a suspected cardiac condition to a cardiologist for further evaluation and treatment.
2. A dermatologist refers a patient with a suspicious skin lesion to a dermatopathologist for a biopsy and pathological examination.
3. A pediatrician refers a child with developmental delays to a pediatric neurologist for a comprehensive evaluation.
4. An orthopedic surgeon refers a patient with a complex fracture to a hand specialist for specialized treatment.
5. A primary care provider refers a patient with chronic back pain to a pain management specialist for further assessment and treatment options.