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    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g0454-dme-face-to-face-documentation-np-pa-cns
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    HCPCS G0454: DME Face-to-Face Documentation by NPP

    HCPCS Level II code G0454 documents a face-to-face evaluation performed by a nurse practitioner, physician assistant, or clinical nurse specialist to determine medical necessity for durable medical equipment (DME); this represents an evaluation/assessment service typically provided in an office or outpatient clinic setting to support DME prescriptions and documentation requirements for equipment delivery.

    For related coverage guidance, see recent payer policy updates: Esophagogastroduodenoscopy (EGD) Coverage Policy, Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD), Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing.

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    Table of contents

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    Clinical & Coding Specifications

    Clinical Context

    A 72-year-old male with advanced chronic obstructive pulmonary disease (COPD) and progressive mobility impairment is referred for durable medical equipment (DME) evaluation after discharge from a pulmonary exacerbation. The patient has increased dyspnea on exertion, uses supplemental oxygen at home, and reports difficulty ambulating more than a few steps without assistance. A nurse practitioner performs a face-to-face visit to assess functional status, home environment, and DME needs (such as a portable oxygen concentrator, power or manual wheelchair, or hospital bed). The nurse practitioner documents medical necessity, trial of conservative measures, specific equipment requested, and expected duration of need. The documentation is then reviewed and countersigned by the supervising physician as required by payer or facility policy. Typical workflow steps: referral for DME evaluation; face-to-face assessment by NP/PA/CNS including history, focused physical exam, and functional mobility assessment; documentation of objective findings supporting DME; discussion with patient/caregiver about equipment options; completion of required DME forms; physician review and signature; submission to durable medical equipment supplier and payer for prior authorization and billing using G0454 when applicable.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesOften performed before or during the DME assessment to document medical necessity and link an E/M visit to the DME determination
    99214Office or other outpatient visit for established patient, typically 25 minutesUsed when the face-to-face DME visit requires moderate to high complexity decision making and extended documentation that supports DME need
    97530Therapeutic activities, direct (one-on-one) patient contact by the provider, each 15 minutesMay be used when occupational or physical therapy performs functional mobility testing that informs DME selection
    97032Application of a modality to one or more areas; electrical stimulationOccasionally used in adjunct evaluations when therapy modalities inform functional status for DME decisions
    99497Advance care planning including the explanation and discussion of advance directives, first 30 minutesMay be performed in the same encounter for patients with progressive illness when goals of care discussions coincide with DME planning

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…
    80CPT® Modifier 80 (Assistant Surgeon) is appended to a surgical CPT code when a physician (MD or DO) provides full, continuous assistance throughout the operative procedure. It is intended only for…- Use CPT Modifier -80 when a physician (MD or DO) serves as an assistant surgeon and provides full, continuous assistance throughout the entire operative procedure; append -80 to the surgical CPT…
    82Modifier 82 is appended to a surgical CPT code to indicate that an attending physician acted as an assistant because a qualified resident surgeon was unavailable. In teaching hospitals it documents…- When to use: Append modifier 82 in teaching-hospital settings to indicate a physician served as an assistant surgeon because a qualified resident surgeon was unavailable (includes situations where…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    363L00000XNurse Practitioner(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision mak…
    275N00000XMedicare Defined Swing Bed Hospital UnitA unit of a hospital that has a Medicare provider agreement and has been granted approval from HCFA to provide post-hospital extended care services an…
    207Q00000XFamily Medicine PhysicianFamily Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadt…
    207R00000XInternal Medicine PhysicianA physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
    163WX0800XOrthopedic Registered NurseNursing Service Providers · Registered Nurse
    146M00000XIntermediate Emergency Medical TechnicianAn Intermediate EMT is an individual trained and certified to perform intermediate life support treatment in medical emergencies based on individual s…
    101YS0200XSchool CounselorBehavioral Health & Social Service Providers · Counselor

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 3

    7 rows

    PolicyPayerEffective Date
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01
    Celiac Disease TestingOscar Health2026-10-01

    Related Codes

    HCPCS-G9490-HOME-ASSESSMENT-NON-HOMEBOUND

    HCPCS G9490: Home Visit Patient Assessment for Non-Homebound Beneficiary

    HCPCS-G0008-INFLUENZA-VACCINE-ADMINISTRATION

    HCPCS G0008: Administration of Influenza Virus Vaccine

    HCPCS-G0009-PNEUMOCOCCAL-VACCINE-ADMINISTRATION

    HCPCS G0009: Administration of Pneumococcal Vaccine

    HCPCS-G0010-HEPATITIS-B-VACCINE-ADMINISTRATION

    HCPCS G0010: Administration of Hepatitis B Vaccine

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

    HCPCS G0011: Individual PrEP Counseling, HIV Risk Assessment

    HCPCS-G0012-PRE-EXPOSURE-PROPHYLAXIS-INJECTION-HIV-PREVENTION

    HCPCS G0012: Injection of PrEP Drug for HIV Prevention

    HCPCS-G0013-PREP-INDIVIDUAL-COUNSELING-HIV-RISK-REDUCTION

    HCPCS G0013: Individual PrEP Counseling by Clinical Staff

    HCPCS-G0017-PSYCHOTHERAPY-CRISIS-FIRST-60-MINUTES-NON-OFFICE

    HCPCS G0017: Psychotherapy for Crisis, First 60 Minutes

    HCPCS-G0018-PSYCHOTHERAPY-CRISIS-ADDITIONAL-30-MINUTES-NON-OFFICE

    HCPCS G0018: Psychotherapy for Crisis, Additional 30 Minutes

    HCPCS-G0019-COMMUNITY-HEALTH-INTEGRATION-SDOH-CARE-COORDINATION

    HCPCS G0019: Community Health Integration, Person-Centered Assessment

    Showing 1–10 of 1996

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    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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