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    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g2181-bmi-not-documented-medical-reason-or-patient-refusal
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    HCPCS G2181: BMI Not Documented Due to Medical Reason or Patient Refusal

    HCPCS Level II code G2181 indicates that body mass index (BMI) was not documented due to a medical reason or because the patient refused height or weight measurement, representing a documentation exception for vital sign capture during an outpatient clinical visit; service type is vital signs/documentation exception and the typical site of service is ambulatory/office-based care.

    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 68-year-old patient presents for a routine chronic disease management visit in an outpatient primary care clinic. The visit includes medication review, blood pressure check, and counseling for diabetes and hypertension. The clinician intends to document body mass index (BMI) as part of the visit but is unable to obtain height and/or weight because the patient refuses to stand on the scale and declines a height measurement due to acute dizziness and fall risk. The clinician documents the medical reason for not obtaining measurements (symptomatic vertigo and recent syncope) and records the patient refusal in the medical record. The practice bills the encounter with HCPCS Level II code G2181 to indicate BMI was not documented due to a medical reason or patient refusal. Typical workflow steps: clinician assesses and documents the clinical visit, documents the specific reason for missing height/weight (medical contraindication or patient refusal), codes the visit with the appropriate E/M or chronic care CPT code, and appends G2181 as a supporting HCPCS Level II code to explain absence of BMI in the record. Typical site of service: outpatient clinic and physician office visits; may also apply to home health or domiciliary visits when measurement is not feasible.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesCommon E/M code for a visit where BMI would normally be documented; G2181 supports omission of BMI when not obtained.
    99214Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutesUsed for more complex office visits where BMI is customarily recorded but may be absent due to medical reason or patient refusal.
    99304Nursing facility initial comprehensive preventive medicine evaluation and management of new or established patientFacility-based visit where weight/height may be unobtainable; G2181 documents BMI omission.
    99307Subsequent nursing facility care, typically 35 minutesFollow-up visits in long-term care where BMI may not be measured due to patient condition; G2181 explains missing BMI.
    99406Smoking and tobacco use cessation counseling, intermediate, 3-10 minutesPreventive counseling often performed during visits where BMI is documented; G2181 indicates BMI was not recorded when applicable.

    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…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    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…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    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…
    208D00000XGeneral Practice PhysicianA physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.
    207T00000XNeurological Surgery PhysicianA neurological surgeon provides the operative and non-operative management (i.e., prevention, diagnosis, evaluation, treatment, critical care, and reh…
    163W00000XRegistered Nurse(1) A registered nurse is a person qualified by graduation from an accredited nursing school (depending upon schooling, a registered nurse may receive…
    152WC0802XCorneal and Contact Management OptometristThe professional activities performed by an Optometrist related to the fitting of contact lenses to an eye, ongoing evaluation of the cornea's ability…
    1835S0206XSolid Organ Transplant PharmacistA licensed pharmacist who has demonstrated specialized knowledge and skill delivering direct patient care and the safe and effective use of medication…
    208VP0000XPain Medicine PhysicianPain Medicine is a primary medical specialty based on a distinct body of knowledge and a well-defined scope of clinical practice that is founded on sc…

    Related ICD-10-CM Codes

    27 rows

    ICD-10-CM CodeDescription
    E66.01Morbid (severe) obesity due to excess calories
    F40.9Phobic anxiety disorder, unspecified
    F41.9Anxiety disorder, unspecified
    F45.21Hypochondriasis
    F50.9Eating disorder, unspecified
    R63.0Anorexia
    R63.4Abnormal weight loss
    R63.5Abnormal weight gain
    R68.89Other general symptoms and signs
    R99Ill-defined and unknown cause of mortality

    Showing 1–10 of 27

    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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