Summary & Overview
HCPCS G0045: 90-Day Clinical Follow-Up and mRS Assessment After Endovascular Stroke Intervention
HCPCS Level II code G0045 denotes a structured clinical follow-up visit and Modified Rankin Scale (mRS) assessment at 90 days after an endovascular stroke intervention. This code captures a clinically important outcome measure used to document functional recovery and support continuity of care after acute reperfusion therapies. Nationally, standardized reporting of 90-day outcomes informs quality measurement, care coordination, and post-acute planning for stroke patients.
Key payers covered in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines common billing conventions, where available, and highlights clinical context for documentation of the mRS at the 90-day time point.
Readers will learn the clinical intent of G0045, expected sites of service, and how the code fits into post-stroke outcome assessment workflows. The report provides benchmarks and policy context when available, and points to documentation elements needed to justify the service. Data not available in the input is noted where specific payer policy details, associated taxonomies, ICD-10 mappings, and related codes are absent. The summary is written for a national audience and is intended to inform coding, quality reporting, and administrative planning related to endovascular stroke follow-up care.
Billing Code Overview
HCPCS Level II code G0045 represents clinical follow-up and Modified Rankin Scale (mRS) assessment at 90 days following endovascular stroke intervention. The service is a post-procedural neurological outcome assessment focused on functional status at the 90-day milestone after an endovascular procedure for acute ischemic stroke.
Service Type: Clinical follow-up and outcome assessment
Typical Site of Service: Outpatient clinic or ambulatory care setting, which may include specialty stroke clinics or neurology follow-up visits where functional outcome and rehabilitation progress are evaluated.
Clinical & Coding Specifications
Clinical Context
A 68-year-old male presented with an acute ischemic stroke due to large vessel occlusion and underwent successful endovascular thrombectomy. The patient was discharged to home with outpatient follow-up arranged. At approximately 90 days after the endovascular stroke intervention, a clinician-conducted visit assesses clinical recovery, documents the modified Rankin Scale (mRS) score, reviews rehabilitation progress, medication adherence (antiplatelet/anticoagulant therapy), and screens for post-procedural complications (recurrent ischemia, hemorrhagic transformation, access-site issues, and medical comorbidities). The workflow typically includes scheduling the 90-day visit by the neurointerventional team or stroke clinic, collecting interim history from patient or caregiver, performing a focused neurological exam, assigning an mRS score, updating the problem list and medication list, coordinating ongoing rehabilitation and outpatient therapies, and generating the documentation required for billing using G0045. Typical site of service is an outpatient clinic or hospital-based outpatient department. Common payors involved in authorization and payment include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component |