Summary & Overview

HCPCS G8431: Positive Depression Screen with Documented Follow-Up Plan

HCPCS Level II code G8431 denotes documentation of a positive depression screening together with a documented follow-up plan. This code captures a discrete quality and clinical-documentation event tied to behavioral health screening in ambulatory care. It matters nationally because depression screening and linkage to follow-up are central to population health initiatives, quality measurement, and payer performance programs that seek to improve mental health outcomes and reduce downstream morbidity.

Key payers included in coverage and performance review are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what G8431 represents clinically and operationally, how it is used across outpatient primary care and community settings, and which payers commonly recognize the code. The publication also summarizes typical reporting contexts, common modifiers associated with similar HCPCS Level II use (listed elsewhere), and where to locate policy updates and billing guidance.

The report provides national benchmarking context and documentation expectations, highlights implications for clinical workflows and quality measurement, and points to where to review payer-specific coverage rules. Data not available in the input for certain fields such as associated taxonomies, ICD-10 pairings, and related codes is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG8431HCPCS Level IIdepression screeningbehavioral healthquality measureambulatory caredocumentationfollow-up plan

Billing Code Overview

HCPCS Level II code G8431 indicates that screening for depression is documented as being positive and a follow-up plan is documented. The service represented is a depression screening with documented positive result and an associated follow-up plan, which is typically delivered as part of primary care or behavioral health screening services. The typical site of service is ambulatory outpatient settings such as physician offices, clinics, and community health centers where routine mental health screening and brief follow-up planning occur.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A primary care clinician screens a 34-year-old adult patient using a validated depression screening tool (for example, PHQ-9) during a routine wellness visit. The screening result is positive for depressive symptoms. The clinician documents the positive screen, assesses severity and safety (including suicidal ideation), and records a follow-up plan in the chart such as initiating psychotherapy referral, prescribing an antidepressant, arranging close follow-up within 2–4 weeks, or providing crisis resources. Typical site of service is an outpatient clinic or primary care office where preventive screening and behavioral health coordination occur. Documentation includes the screening instrument score, clinical assessment, risk/safety evaluation, and a clear follow-up plan or referral documented in the medical record. The service is administrative and nondiscrete from E/M care but is reportable when specific payor requirements for G8431 are met and documented.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required to document and manage a positive depression screen involves substantially greater physician work than typical (document rationale and time).
`23`	Unusual anesthesia	Not typically applicable to this service; included for completeness if anesthesia is unexpectedly required.
`52`	Reduced services	Use if the depression screening process was begun but substantially reduced or incomplete.
`53`	Discontinued procedure	Use if screening was started but discontinued for patient safety or other valid reason.
`55`	Split surgical care	Not typically applicable but may be present when documentation responsibilities are shared across providers.
`56`	Pre-operative care	Not applicable to routine screening; rarely used if screening occurs as part of pre-op evaluation and another provider will assume care.
`62`	Two surgeons	Not applicable in most cases; included for rare interdisciplinary co-management documentation.
`QK`	Medical direction of two, three, or four CRNAs	Use only if certified registered nurse anesthetist services intersect with this encounter (rare).
`QX`	CRNA service with surgical assistant	Rare for this service; included when CRNA documentation is required alongside the encounter.
`QY`	Service furnished under a Medicare-approved CAHCRNA demonstration	Not typically relevant; include only when applicable per program rules.
`XE`	Separate encounter	Use when the depression screening and documented follow-up plan are performed during a distinct separate encounter from other services.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for surgical assists	Not typically applicable; include only if encounter roles require this modifier.
`CQ`	Service furnished by a nonphysician practitioner in hospice	Use when a nonphysician practitioner documents screening and follow-up in hospice settings.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians commonly perform screening and document follow-up plans.
`207R00000X`	Internal Medicine	Internists perform screening during adult preventive and chronic care visits.
`208000000X`	General Practice	General practitioners in outpatient settings frequently document screening and plans.
`367A00000X`	Psychiatry & Neurology — Psychiatry	Psychiatrists receive referrals and document follow-up diagnostic and treatment plans.
`363L00000X`	Clinical Social Worker	Behavioral health clinicians coordinate psychotherapy referrals and follow-up plans.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F32.0`	Major depressive disorder, single episode, mild	Common diagnosis when screening detects depressive symptoms requiring treatment or follow-up.
`F32.1`	Major depressive disorder, single episode, moderate	Indicates moderate symptomatology documented after a positive screen guiding follow-up intensity.
`F32.2`	Major depressive disorder, single episode, severe without psychotic features	Represents more severe presentations identified after screening necessitating urgent follow-up.
`F33.0`	Major depressive disorder, recurrent, mild	Used when patient has recurrent episodes documented and follow-up plan addresses relapse prevention.
`F41.1`	Generalized anxiety disorder	Anxiety commonly co-occurs with depression; positive screens often lead to evaluation for comorbid anxiety.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Commonly performed during the same visit in which depression screening is completed and a follow-up plan is documented.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used when the visit requires moderate to high complexity decision making and includes management of positive depression screening.
`99420`	Administration and interpretation of health risk assessment instrument (HRA)	May be performed alongside depression screening when broader behavioral health risk assessments are completed.
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory) with scoring and documentation, per standardized instrument	Often used when a brief validated screening tool (such as PHQ-9) is administered and scored during the encounter.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Behavioral counseling codes commonly billed in the same visit when addressing behavioral health needs identified during screening.