G0028 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS G0028: Medical Reason for Not Screening for Tobacco Use

HCPCS Level II code G0028 denotes documentation of the medical reason for not performing tobacco-use screening, such as limited life expectancy or another medical contraindication. Nationally, the code is used to record clinical justification when a standard preventive measure is appropriately omitted; accurate use supports quality reporting and clarifies care decisions in patient records. Key payers in national discussions include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. This publication summarizes what the code represents, the clinical contexts in which it is applied, and the operational implications for billing and documentation. Readers will find a concise overview of the code’s purpose, common sites of service and service type, an outline of typical payer coverage considerations, and guidance on where to look for related policy updates and quality-measure interactions. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG0028HCPCS Level IItobacco screeningpreventive servicesclinical documentationquality reportingoutpatient carebilling and coding

Billing Code Overview

HCPCS Level II code G0028 documents the medical reason(s) for not screening for tobacco use, for example when a patient has a limited life expectancy or another medical reason that makes screening inappropriate. This code captures clinician documentation justifying why the standard preventive screening was not performed.

Service type: Clinical documentation of medical justification for omission of a preventive screening
Typical site of service: Any outpatient or ambulatory clinical setting where tobacco-use screening would normally be considered, including primary care and specialty clinics

Clinical & Coding Specifications

Clinical Context

A common scenario involves an elderly patient with advanced metastatic cancer or severe dementia presenting to a primary care clinic or oncology outpatient visit. The clinician reviews preventive care checklists and documents tobacco use screening is not performed because the patient has a limited life expectancy and goals of care emphasize comfort only. The workflow: intake staff record smoking status when possible; during bedside evaluation the clinician assesses prognosis, current symptom burden, and patient's ability to participate in counseling. When a valid medical reason exists (for example, terminal illness, severe cognitive impairment, or acute critical illness), the clinician documents the specific medical reason in the medical record, links it to the visit encounter, and bills HCPCS code G0028 to indicate documentation of medical reason(s) for not screening for tobacco use. The typical sites of service are outpatient clinic, oncology infusion center, hospice or palliative care clinic, and skilled nursing facility during a physician or advanced practice clinician encounter.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	When the visit requires substantially greater work due to complexity of documenting exclusion rationale in a complex patient.

HCPCS G1012: Clinical Decision Support Mechanism (agileMD)

HCPCS-G9628-BOWEL-INJURY-POSTOPERATIVE-UP-TO-30-DAYS

HCPCS G9628: Bowel Injury at Time of Surgery or Within 30 Days

HCPCS-G2164-PRIOR-INFLUENZA-VACCINE-ADVERSE-REACTION

HCPCS G2164: Prior Influenza Vaccine Adverse Reaction

HCPCS-G0010-HEPATITIS-B-VACCINE-ADMINISTRATION

HCPCS G0010: Administration of Hepatitis B Vaccine

HCPCS-G9815-DEATH-NOT-OCCURRING-DURING-ACUTE-HOSPITALIZATION

HCPCS G9815: Death Did Not Occur During Index Acute Care Hospitalization

HCPCS-G0011-PREP-COUNSELING-HIV-RISK-REDUCTION-ADHERENCE

HCPCS G0011: Individual PrEP Counseling, HIV Risk Assessment

HCPCS-G8561-OTOLOGIC-REFERRAL-INELIGIBILITY-ACTIVE-DRAINAGE-HISTORY

HCPCS G8561: Otologic Referral Ineligibility Due to Active Ear Drainage

HCPCS-G9832-BREAST-CANCER-STAGE-I-T1C

HCPCS G9832: AJCC Stage I (T1c) at Breast Cancer Diagnosis

HCPCS-G9170-MEMORY-FUNCTIONAL-LIMITATION-DISCHARGE-STATUS

HCPCS G9170: Memory Functional Limitation, Discharge Status

HCPCS-G9169-MEMORY-FUNCTIONAL-LIMITATION-THERAPY-REPORTING

HCPCS G9169: Memory Functional Limitation, Episode Reporting

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians commonly document tobacco screening exclusions during outpatient visits.
`207R00000X`	Internal Medicine	Hospitalists and internists document medical reasons for not screening in complex adult patients.
`208000000X`	Pediatrics	Pediatricians may document exclusions for developmental or medical reasons in adolescent populations.
`208D00000X`	Hospice and Palliative Medicine	Specialists frequently document limited life expectancy or comfort-focused care as reasons to omit screening.
`363A00000X`	Nurse Practitioner	Advanced practice clinicians in clinics and SNFs commonly document the exclusion rationale.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C80.1`	Malignant (primary) neoplasm, unspecified site — in remission	Advanced malignancy or end-stage cancer where limited life expectancy may justify omitting tobacco screening.
`F03.90`	Unspecified dementia without behavioral disturbance	Severe cognitive impairment limiting the patient's ability to participate in screening or counseling.
`Z51.5`	Encounter for palliative care	Documented palliative goals of care that prioritize comfort and may exclude preventive screenings.
`R99`	Ill-defined and unknown cause of mortality	Very high mortality risk where preventive screening is not clinically appropriate.
`Z74.3`	Need for continuous supervision	Patients requiring full-time care where screening and counseling are not feasible.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99401`	Preventive medicine counseling, individual, approximately 15 minutes	Counseling for tobacco cessation when screening and counseling are appropriate; may be billed when screening is performed instead of documenting exclusion.
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Commonly used when tobacco screening identifies use and brief counseling is provided; contrasts with billing `G0028` when screening is not done for medical reasons.
`99407`	Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes	Used when intensive cessation counseling is delivered following positive screening; not used when `G0028` documents exclusion.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Typical E/M visit during which the clinician documents medical reason(s) for not screening and bills `G0028` in addition to the visit code when appropriate.
`G0438`	Annual wellness visit, initial	Preventive visit during which tobacco screening is expected; `G0028` is billed when the clinician documents a medical reason to omit tobacco screening during an AWV.

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