G8461 HCPCS Reimbursement & Policy | OpenPayer

Summary & Overview

HCPCS G8461: Patient Receiving Antiviral Treatment for Hepatitis C

HCPCS Level II code G8461 documents that a patient received antiviral treatment for hepatitis C during the measurement period. This status code is used in clinical and quality measurement contexts to capture receipt of antiviral therapy, an important step in hepatitis C management that impacts patient outcomes and population-level targets for viral eradication. Nationally, documenting antiviral treatment informs quality reporting, care coordination, and performance measurement for chronic hepatitis C care pathways.

Key payers in the national context include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find benchmarks and practical context for how G8461 is used in quality measurement frameworks, an explanation of its clinical significance for hepatitis C treatment tracking, and notes on common sites of service where the code is typically recorded. The publication highlights policy-relevant considerations for payers and health systems such as implications for quality reporting, documentation practices, and alignment with treatment guidelines. Data not available in the input is noted where payer-specific coverage policies, modifiers, taxonomies, ICD-10 pairings, and related service-line details would normally be summarized.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG8461HCPCS Level IIhepatitis Cantiviral treatmentquality measurementoutpatienthepatologyinfectious disease

Billing Code Overview

HCPCS Level II code G8461 indicates patient receiving antiviral treatment for hepatitis C during the measurement period. This code is used to denote that a patient diagnosed with hepatitis C received an antiviral regimen within the specified measurement timeframe.

Service type: Antiviral treatment management and administration
Typical site of service: Outpatient clinical settings such as specialty hepatology or infectious disease clinics, ambulatory care centers, and hospital outpatient departments

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 54-year-old patient with chronic hepatitis C virus infection presents to a hepatology clinic and is prescribed a direct-acting antiviral (DAA) regimen during the measurement period. The clinical workflow begins with initial evaluation: review of prior medical records, confirmation of active HCV RNA by laboratory testing, baseline liver staging by transient elastography or fibrosis biomarkers, assessment for drug–drug interactions, and counseling about adherence and potential side effects. The patient returns for medication initiation and receives the antiviral prescription, with pharmacy dispensation documented in the medical record. Follow-up visits occur at 4–8 weeks to monitor adherence, symptoms, and laboratory tests (HCV viral load, liver function tests, renal function) and again at 12 weeks after completion of therapy to assess sustained virologic response. Documentation of antiviral treatment during the measurement period is the key element captured by G8461 and may appear across ambulatory hepatology, infectious disease, primary care, or specialty pharmacy records. Typical sites of service include outpatient clinics, specialty infusion or pharmacy dispensing settings, and ambulatory treatment centers. Typical patient scenario: adult with chronic HCV genotype 1 or 3, previously untreated or treatment-naïve, initiated on a recommended oral DAA regimen with documented prescription fill and clinical monitoring during the reporting period.

Coding Specifications

Modifier	Description	When to Use
`25`

HCPCS G9696: Documentation of Reason for Not Prescribing Long-Acting Inhaled Bronchodilator

HCPCS-G0045-90-DAY-MRS-CLINICAL-FOLLOW-UP-ENDOVASCULAR-STROKE

HCPCS G0045: 90-Day Clinical Follow-Up and mRS Assessment After Endovascular Stroke Intervention

HCPCS-G9226-FOOT-EXAMINATION-COMPREHENSIVE-FOOT-SCREENING

HCPCS G9226: Comprehensive Foot Examination, Sensory and Vascular Assessment

HCPCS-G9291-SPECIMEN-SITE-NSCLC-NOS-PATHOLOGY

HCPCS G9291: Specimen Site Other Than Lung, NSCLC–NOS

HCPCS-G6003-RADIATION-SINGLE-PORT-UP-TO-5-MEV

HCPCS G6003: Radiation Treatment Delivery, Single Port or Parallel Opposed Ports, Up to 5 mev

HCPCS-G9443-STATIN-NOT-PRESCRIBED-AT-DISCHARGE

HCPCS G9443: Statin Not Prescribed at Discharge

HCPCS-G9553-PRIOR-THYROID-DISEASE-DIAGNOSIS

HCPCS G9553: Prior Thyroid Disease Diagnosis

HCPCS-G9584-OPIOID-MISUSE-RISK-ASSESSMENT

HCPCS G9584: Opioid Misuse Risk Assessment

HCPCS-G0030-TOBACCO-CESSATION-SCREENING-INTERVENTION

HCPCS G0030: Tobacco Use Screening and Cessation Intervention

HCPCS-G0034-PALLIATIVE-CARE-MEASURE

HCPCS G0034: Patients Receiving Palliative Care During Measurement Period

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207RH0000X`	Infectious Disease	Specialists who manage complex HCV cases and select antiviral regimens.
`207RC0000X`	Gastroenterology	Hepatology-focused gastroenterologists who stage liver disease and manage treatment.
`207L00000X`	Internal Medicine	Primary care physicians involved in screening, diagnosis, and coordination of antiviral therapy.
`3336S0300X`	Clinical Pharmacist	Pharmacists who perform medication reconciliation, DAA regimen selection, and adherence counseling.
`261QM0800X`	Family Medicine	Family physicians managing HCV treatment in community settings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`B18.2`	Chronic viral hepatitis C	Primary diagnosis indicating chronic HCV infection requiring antiviral therapy and captured for `G8461`.
`B19.20`	Unspecified viral hepatitis C without hepatic coma	Used when hepatitis C is documented but chronicity or liver status is unspecified; may be present in records documenting treatment.
`K74.60`	Unspecified cirrhosis of liver	Indicates advanced liver disease that affects regimen selection and monitoring during antiviral therapy.
`K70.30`	Alcoholic cirrhosis of liver without ascites	Relevant when alcohol-related liver disease coexists and impacts treatment planning and outcomes.
`E11.9`	Type 2 diabetes mellitus without complications	Common comorbidity that influences management and monitoring during antiviral therapy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`36415`	Collection of venous blood by venipuncture	Frequently performed to obtain baseline and on-treatment HCV RNA, liver function, and renal panels.
`80053`	Comprehensive metabolic panel (CMP)	Used to monitor liver enzymes and renal function during antiviral therapy.
`87520`	Infectious agent detection by nucleic acid (e.g., HCV RNA quantitative)	Performed to confirm active infection at baseline and to document virologic response during and after therapy.
`99406`	Smoking and tobacco use cessation counseling, intermediate	Often billed when behavioral counseling is provided as part of comprehensive HCV care (smoking cessation counseling).
`99070`	Supplies and materials (e.g., medication administration supplies)	Used when additional supplies related to medication administration or monitoring are billed.

OpenPayer