Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g8419-bmi-outside-normal-no-follow-up-documented
    Ask Trek AI about this page

    HCPCS Level II G8419: BMI Outside Normal Parameters, No Follow‑Up Plan Documented

    HCPCS Level II code G8419 documents that a patient’s body mass index (BMI) was recorded as outside normal parameters and no follow-up plan or reason was documented; this code represents a quality/documentation measure typically captured during preventive or primary care visits such as annual wellness visits or routine outpatient primary care encounters and is used to flag missing counseling or care-planning when abnormal BMI is found in the outpatient ambulatory setting.

    For related coverage guidance, see recent payer policy updates: Esophagogastroduodenoscopy (EGD) Coverage Policy, Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD), Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease.

    Customize your policy alerts

    Sign up for hcpcs G8419 policy alerts

    Get alerted when payer policies referencing G8419 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Table of contents

    Progress1 / 7

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    Clinical & Coding Specifications

    Clinical Context

    A 45-year-old patient presents to a primary care clinic for an annual visit. Vital signs and anthropometric measurements are obtained as part of routine intake; the patient’s height and weight produce a body mass index (BMI) outside normal parameters (for example, BMI ≥30 kg/m2 indicating obesity or BMI ≤18.5 kg/m2 indicating underweight). The BMI value is recorded in the electronic medical record, but during the encounter no documented follow-up plan is recorded and no medical justification or reason for the lack of follow-up is provided. Typical workflow: intake staff measure height and weight, the clinician or rooming nurse calculates and documents BMI, clinician documents assessment and plan; documentation is incomplete when the plan portion related to abnormal BMI is omitted. This billing code G8419 is used to identify the chart-level documentation deficiency where BMI is abnormal and no follow-up plan or reason is documented. Typical site of service is an outpatient ambulatory clinic such as a primary care office or community health center. Common patient scenarios include new or established primary care visits, annual wellness visits, or chronic disease follow-up appointments where BMI is recorded but counseling, referral, or plan is not documented.

    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 visits where BMI is measured; documentation should include assessment and plan addressing abnormal BMI.
    99214Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutesUsed for more complex outpatient visits where abnormal BMI and associated comorbidities require additional decision-making; documentation must include follow-up plan.
    99385Initial comprehensive preventive medicine evaluation and management of an individual, 18-39 yearsPreventive visit where BMI is routinely recorded and a documented follow-up plan is expected when BMI is outside normal parameters.
    G0438Annual wellness visit, initial, includes personalized prevention plan of service (PPPS)Medicare preventive visit where abnormal BMI should prompt documented counseling or a plan; omission can trigger a deficiency code like G8419.
    99401Preventive medicine counseling, individual, approximately 15 minutesCounseling services often billed in conjunction with an E/M when diet, exercise, or weight management counseling is provided for abnormal BMI; absence of documentation of these services is relevant to G8419.

    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.
    152W00000XOptometristDoctors of optometry (ODs) are the primary health care professionals for the eye. Optometrists examine, diagnose, treat, and manage diseases, injurie…
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    207RH0002XHospice and Palliative Medicine (Internal Medicine) PhysicianAn internal medicine physician with special knowledge and skills to prevent and relieve the suffering experienced by patients with life-limiting illne…
    164W00000XLicensed Practical NurseAn individual with post-high school vocational training and practical experience in the provision of nursing care at a level less than that required f…
    207ZP0105XClinical Pathology/Laboratory Medicine PhysicianA pathologist deals with the causes and nature of disease and contributes to diagnosis, prognosis and treatment through knowledge gained by the labora…

    Related ICD-10-CM Codes

    24 rows

    ICD-10-CM CodeDescription
    E03.9Hypothyroidism, unspecified
    E11.22Type 2 diabetes mellitus with diabetic chronic kidney disease
    E11.65Type 2 diabetes mellitus with hyperglycemia
    E11.9Type 2 diabetes mellitus without complications
    E16.2Hypoglycemia, unspecified
    E55.9Vitamin D deficiency, unspecified
    E66.01Morbid (severe) obesity due to excess calories
    E66.1Drug-induced obesity
    E66.3Overweight
    E66.9Obesity, unspecified

    Showing 1–10 of 24

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 3

    10 rows

    PolicyPayerEffective Date
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01
    Celiac Disease TestingOscar Health2026-10-01
    Laboratory Testing for the Diagnosis of Inflammatory Bowel DiseaseOscar Health2026-10-01
    Percutaneous Electrical Nerve Field Stimulation (PENFS)Cigna2026-09-15
    Colorectal Cancer ScreeningBlue Cross Blue Shield - New Mexico2026-09-04

    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

    • More pages

    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.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.