Summary & Overview
HCPCS G1006: Clinical Decision Support Appropriateness Test
HCPCS Level II code G1006 denotes a clinical decision support mechanism test of appropriateness as defined by the Medicare Appropriate Use Criteria program. Nationally, documenting the use of an appropriateness-focused clinical decision support tool matters for compliance with program requirements and for transparent clinical documentation when ordering imaging or other resource-intensive tests. The code serves as a standardized way to indicate that a clinician used an electronic decision support mechanism to assess whether a test met established appropriateness criteria.
Key payers discussed include Aetna, Blue Cross Blue Shield plans, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code's clinical purpose, the service settings where it is typically applied, and the implications for documentation and billing workflows. The publication outlines benchmarks and policy context relevant to use of clinical decision support for appropriateness determinations, summarizes payer coverage considerations, and highlights coding and clinical context that organizations should track when implementing or auditing use of this code.
This summary is intended for national audiences seeking concise information on HCPCS Level II code G1006, its role in appropriateness workflows, and the payer landscape affecting its application.
Billing Code Overview
HCPCS Level II code G1006 indicates a clinical decision support mechanism test appropriate, as defined by the Medicare Appropriate Use Criteria program. The code documents the use of a clinical decision support tool to determine the appropriateness of a specific test or service under the program's criteria.
Service Type: Clinical decision support / appropriateness determination
Typical Site of Service: Any setting where clinical decision support for test appropriateness is applied, including outpatient clinics, hospital outpatient departments, and other sites where ordering clinicians use electronic decision support tools to evaluate test appropriateness.
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Clinical & Coding Specifications
Clinical Context
A 68-year-old male with known coronary artery disease is referred for an outpatient diagnostic cardiac imaging study to evaluate new onset chest pain. Prior to ordering the advanced imaging test, the ordering clinician uses the facility's certified appropriate use criteria (AUC) clinical decision support (CDS) tool to check whether the proposed imaging is appropriate under Medicare AUC requirements. The CDS mechanism processes the patient’s clinical data (symptoms, recent ECG findings, prior interventions) and returns a test-appropriate determination. Documentation of the CDS consultation and the G1006 claim is recorded in the electronic health record and billing workflow to indicate that the clinical decision support mechanism determined the test was appropriate as defined by the Medicare Appropriate Use Criteria program. Typical sites of service include outpatient hospital outpatient departments and ambulatory imaging centers where advanced diagnostic imaging is ordered and billed to Medicare.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When substantial additional work supports documentation for an associated service beyond typical effort related to ordering or documenting the CDS consultation. |