Summary & Overview
HCPCS G8460: Hepatitis C Week 12 RNA Ineligible, Not on Antiviral
HCPCS Level II code G8460 records a clinician's determination that a patient with hepatitis C is not an eligible candidate for quantitative RNA testing at week 12 and is not receiving antiviral treatment. As a documentation-focused code, G8460 matters nationally because it standardizes reporting of clinical eligibility assessments that can affect care pathways, follow-up planning, and compliance reporting related to hepatitis C management.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will gain a concise understanding of the code's clinical purpose, typical settings where it is used, and how it fits into hepatitis C care workflows. The publication summarizes benchmarks and reporting practices where available, outlines common clinical contexts in which the code is applied, and flags where input data are not available. The intent is to provide clinicians, coders, and policy analysts with clear, actionable context around documentation-based reporting for week-12 hepatitis C RNA testing in patients not on antiviral therapy.
Billing Code Overview
HCPCS Level II code G8460 documents that a clinician determined the patient is not an eligible candidate for quantitative RNA testing at week 12 and that the patient is not receiving antiviral treatment for hepatitis C. This code captures a clinical assessment and decision documented in the medical record rather than a procedure or laboratory service.
-
Service type: Clinical assessment / medical decision-making related to hepatitis C management
-
Typical site of service: Outpatient clinic, specialty infectious disease or hepatology visit, or ambulatory care setting
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient with chronic hepatitis C virus (HCV) infection attends a 12-week follow-up visit during a course of antiviral therapy monitoring. The clinician documents that the patient is not an eligible candidate for quantitative HCV RNA testing at week 12 because the patient is not receiving antiviral treatment; therefore, quantitative RNA measurement is not clinically indicated for assessing treatment response. The workflow includes review of prior laboratory results, medication reconciliation confirming no active direct-acting antiviral (DAA) therapy, clinical assessment for ongoing HCV-related symptoms, and documentation in the medical record that quantitative HCV RNA testing at week 12 is not applicable. Typical sites of service include outpatient hepatology or infectious disease clinics, primary care clinics managing HCV, or hospital-based outpatient departments where HCV care is coordinated. The typical patient scenario involves counseling on HCV management options, consideration of treatment initiation, or deferral of therapy, with documentation to support the absence of week-12 quantitative RNA testing due to lack of antiviral therapy.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when an E/M visit is provided on the same day as a related procedure and is distinct from routine documentation about HCV treatment eligibility |