HCPCS G1013: Clinical Decision Support for Imaging Appropriate Use Criteria - OpenPayer

Summary & Overview

HCPCS G1013: Clinical Decision Support for Imaging Appropriate Use Criteria

HCPCS Level II code G1013 denotes the use of a clinical decision support mechanism to assess imaging orders against Medicare Appropriate Use Criteria (AUC). Nationally, this code reflects an effort to standardize imaging utilization, improve diagnostic appropriateness, and align care with evidence-based guidance. Use of G1013 can affect documentation workflows, electronic health record integration, and reporting practices across outpatient and ambulatory care settings.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a national perspective on the code's clinical context, how it fits into imaging stewardship efforts, and practical considerations for billing and documentation. The publication summarizes expected service settings, typical documentation triggers, and implications for payer claims processing. It also outlines what to look for in benchmarking and policy updates related to decision support for imaging, and highlights common operational touchpoints for practices adopting AUC decision support.

This summary is intended to inform clinicians, billing professionals, and administrators about the role of G1013 in imaging appropriateness workflows and payer interactions without providing clinical recommendations.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG1013HCPCS Level IIimagingclinical decision supportappropriate use criteriaimaging appropriatenessoutpatient servicesbilling documentation

Billing Code Overview

HCPCS Level II code G1013 represents a clinical decision support mechanism focused on appropriate use criteria (AUC) for imaging as defined by the Medicare Appropriate Use Criteria Program. The code describes a service that documents use of a decision support mechanism to evaluate imaging orders against established evidence-based criteria.

Service Type: Clinical decision support for imaging appropriateness

Typical Site of Service: Outpatient and ambulatory settings where imaging orders are placed, including physician offices, outpatient clinics, and other settings that order diagnostic imaging.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A referring clinician orders an advanced imaging study (for example, CT angiography of the chest for suspected pulmonary embolism). Prior to image acquisition, the facility or ordering provider invokes a Clinical Decision Support (CDS) mechanism that implements the Medicare Appropriate Use Criteria (AUC) program. The CDS tool, identified as G1013 (Clinical decision support mechanism evidencecare imagingcare), receives structured clinical information about the patient — including presenting symptoms, relevant exam findings, and the suspected diagnosis — and returns a documented determination of whether the requested imaging meets AUC. The workflow typically proceeds as follows: the ordering provider enters the imaging order into the electronic health record (EHR) or computerized provider order entry (CPOE) system; the EHR passes defined clinical data to the CDS mechanism; the CDS evaluates the request against evidence-based AUC and returns a result that is captured in the medical record; the ordering clinician reviews the CDS output and either proceeds with the imaging order, modifies the order, or documents a justification for deviation. Typical sites of service include hospital outpatient departments, ambulatory imaging centers, and emergency departments. The typical patient scenario involves an adult patient presenting with new acute symptoms (chest pain, dyspnea, focal neurologic deficits, or recent trauma) where imaging appropriateness varies by clinical context and AUC guidance.

Coding Specifications

Selected modifiers reflect common billing scenarios for imaging examinations and related circumstances when applying G1013 in clinical practice.

Modifier	Description

HCPCS G2193: Pediatric Head Imaging for New-Onset Headache

HCPCS-G9779-BREASTFEEDING-STATUS-ASSESSMENT

HCPCS G9779: Breastfeeding Status During Performance Period

HCPCS-G0559-POST-OPERATIVE-FOLLOW-UP-COMPLEXITY

HCPCS G0559: Post-Operative Follow-Up Visit Complexity

HCPCS-G9214-CD4-CELL-COUNT-OR-PERCENTAGE-RESULTS-DOCUMENTED

HCPCS G9214: CD4+ Cell Count or Percentage Results Documented

HCPCS-G8501-PERIOPERATIVE-QUALITY-ACTIONS-COMPLETED

HCPCS G8501: Perioperative Care Quality Actions Completed

HCPCS-G8930-INITIAL-DEPRESSION-SEVERITY-ASSESSMENT

HCPCS G8930: Assessment of Depression Severity at Initial Evaluation

HCPCS-G6001-ULTRASONIC-GUIDANCE-RADIATION-THERAPY-FIELD-PLACEMENT

HCPCS G6001: Ultrasonic Guidance for Radiation Therapy Field Placement

HCPCS-G1009-CLINICAL-DECISION-SUPPORT-SAGE-HEALTH-MANAGEMENT

HCPCS G1009: Clinical Decision Support Mechanism (Sage Health Management Solutions)

HCPCS-G9873-MDPP-CORE-SESSION-FIRST-ATTENDANCE

HCPCS G9873: MDPP First Core Session Attendance

HCPCS-G2001-POST-DISCHARGE-IN-HOME-NEW-PATIENT-VISIT

HCPCS G2001: Post-Discharge In-Home Visit for New Patient

Showing 1–10 of 1996

`22`	Increased procedural services	Use when additional work or documentation is required due to complexity in performing or documenting the CDS process beyond typical workflow (rarely applied to AUC CDS but may apply in combined encounters).
`23`	Unusual anesthesia	Use if unusual anesthesia is required for the subsequent imaging procedure; modifier may be carried on related imaging claims, not on the CDS mechanism itself.
`52`	Reduced services	Use if the ordered imaging is partially performed or truncated after CDS review leads to an abbreviated study.
`53`	Discontinued procedure	Use if imaging is cancelled after CDS review and documentation supports abandonment for safety or appropriateness reasons.
`54`	Surgical care only	Not typically used for CDS alone; included for circumstances when CDS is part of a broader procedure episode.
`55`	Postoperative management only	Similar to `54`, used when imaging CDS is associated with postoperative care episodes.
`56`	Preoperative management only	Use when preoperative imaging decision-making is the sole segment of the episode and CDS documents pre-op appropriateness.
`62`	Two surgeons	Rare for CDS, included when two practitioners share responsibility for complex imaging-guided procedures related to the CDS-determined care plan.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Use when advanced practice clinician documents CDS interactions in support of imaging decisions tied to surgical care.
`CQ`	Service furnished by a physician or other qualified health care professional in a Federal telemedicine demonstration project	Use when CDS interactions occur as part of an approved federal telemedicine demonstration.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals	Use when CDS-supported imaging is associated with anesthesia that meets `QK` conditions.
`QX`	CRNA service; performed with medical direction by a physician	Use when a CRNA provides anesthesia for imaging procedures that were informed by CDS determinations.
`QY`	Medical direction of one CRNA by an anesthesiologist	Use in anesthesia staffing scenarios associated with imaging procedures determined by CDS.
`FX`	Primary payer provider not contracted	Use when provider is out-of-network for the primary payer in complex billing situations involving imaging services.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Diagnostic Radiology	Radiologists review and act on CDS recommendations to perform, modify, or cancel imaging studies.
`208D00000X`	Emergency Medicine	Emergency physicians frequently trigger CDS for urgent imaging decisions in the ED.
`363L00000X`	Hospitalist	Hospitalists order inpatient imaging and document CDS determinations for hospital-based studies.
`207L00000X`	Interventional Radiology	Interventional radiologists may use CDS outputs when planning image-guided procedures.
`208000000X`	Family Medicine	Primary care and urgent care clinicians use CDS at point of order for outpatient imaging appropriateness.

Related Diagnoses

No ICD-10 codes were provided in the input; the following are commonly associated diagnosis codes for clinical imaging appropriateness reviews governed by the AUC-supported CDS mechanism.

ICD-10 Code	Description	Clinical Relevance
`R07.9`	Chest pain, unspecified	Common presenting symptom prompting chest CT or CT angiography where CDS evaluates appropriateness.
`R06.02`	Shortness of breath	Frequent indication for chest imaging; CDS determines optimal modality and urgency.
`I26.99`	Other pulmonary embolism without acute cor pulmonale	Specific suspected diagnosis for which CT pulmonary angiography appropriateness is routinely assessed.
`S06.0X0A`	Concussion without loss of consciousness, initial encounter	Head trauma scenarios where CDS guides need for head CT.
`M25.561`	Pain in right knee	Musculoskeletal complaints where CDS evaluates need for MRI versus plain radiography.

Related CPT Codes

Common CPT codes are those for the imaging studies that are evaluated by the CDS mechanism and for services that document or follow the imaging decision.

CPT Code	Description	Relationship to This Procedure
`71260`	Computed tomography, chest, without contrast material, followed by contrast material(s) and further sections post contrast, including image postprocessing when performed; thorax	Frequently ordered when `G1013` CDS evaluates chest CT appropriateness for suspected pulmonary embolism or chest pathology.
`71271`	CT angiography, chest, with contrast, including non-contrast and contrast imaging when performed; with further sections post contrast	Commonly linked to CDS determinations for suspected acute pulmonary embolism and vascular evaluation.
`73721`	MRI, any joint of lower extremity; without contrast	Used when CDS evaluates need for musculoskeletal MRI for acute injury or suspected internal derangement.
`74177`	CT abdomen and pelvis with contrast	CDS may be used to determine appropriateness for suspected intra-abdominal pathology or trauma.
`70450`	CT head/brain without contrast	Frequently ordered in acute neurologic presentations where CDS determines if CT is appropriate initial imaging.

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