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    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g8539-functional-outcome-assessment-care-plan
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    HCPCS G8539: Functional Outcome Assessment Positive with Care Plan

    HCPCS Level II code G8539 documents a functional outcome assessment that is recorded as positive using a standardized tool and a care plan based on identified deficiencies is documented within two days of the assessment; this represents a care coordination/service reporting event typically performed as an evaluation and care planning activity in outpatient clinics, rehabilitation settings, or home health visits where standardized functional measures are used to guide follow-up interventions.

    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.

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    Table of contents

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    Clinical & Coding Specifications

    Clinical Context

    A 78-year-old patient recently discharged from the hospital after treatment for an acute ischemic stroke is seen in a post-acute clinic visit by a rehabilitation nurse and physical therapist. A standardized functional outcome assessment (for example, the Modified Rankin Scale, Barthel Index, or the Functional Independence Measure) is administered to quantify mobility, self-care, and activities of daily living. The assessment is documented as positive for deficits in ambulation and transfers. Within two calendar days of that documented assessment the team records a coordinated, individualized care plan that addresses the identified deficits, specifying therapy goals, frequency of skilled rehabilitation services, durable medical equipment needs, home safety recommendations, and planned follow-up. The visit and care plan documentation identify the validating tool, scores, the clinician who performed the assessment, and the date and time of both the assessment and the care plan. This service is billed under G8539 when the documentation meets the requirement that the standardized tool shows a positive functional deficit and the care plan based on those deficits is documented within two days of the assessment. Typical site of service is a post-acute care setting such as inpatient rehabilitation facility, skilled nursing facility, outpatient rehabilitation clinic, or home health visit where functional outcome assessments and care planning are integral to patient management. Typical patient scenarios include recent stroke, hip fracture postoperative patients, major joint replacement with limited mobility, deconditioning after prolonged hospitalization, or progressive neurologic conditions requiring rehabilitation planning.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    97110Therapeutic exercises to develop strength, endurance, range of motion and flexibility (per 15 minutes)Commonly performed after the functional assessment to address identified mobility and strength deficits described in the care plan.
    97112Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception (per 15 minutes)Used when the care plan includes neuromuscular retraining following stroke or neurologic injury identified by the standardized assessment.
    97530Therapeutic activities, direct (one-on-one) patient contact by the provider (per 15 minutes)Applied when the care plan prescribes functional task practice to improve activities of daily living identified as deficient.
    92526Treatment of swallowing dysfunction and/or oral function for feeding (direct therapy)Relevant when the functional assessment documents dysphagia or oral-motor deficits and the care plan includes speech therapy interventions.
    G0156Services performed by a qualified physical therapist in the home health or hospice setting (per 15 minutes)Used in home health settings to bill for skilled therapy visits that implement the care plan developed after the functional assessment.

    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
    207L00000XAnesthesiology PhysicianAn anesthesiologist is trained to provide pain relief and maintenance, or restoration, of a stable condition during and immediately following an opera…
    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…
    251B00000XCase Management AgencyAn organization that is responsible for providing case management services. The agency provides services which assist an individual in gaining access…
    111NI0013XIndependent Medical Examiner ChiropractorA special evaluator not involved with the medical care of the individual examinee that impartially evaluates the care being provided by other practiti…
    229N00000XAnaplastologistAn anaplastologist is a professional who creates prostheses for the face and body. Patients treated include those missing anatomy due to cancer, trau…
    163WP0200XPediatric Registered NurseNursing Service Providers · Registered Nurse
    2080S0010XPediatric Sports Medicine PhysicianA pediatrician who is responsible for continuous care in the field of sports medicine, not only for the enhancement of health and fitness, but also fo…
    341600000XAmbulanceAn emergency vehicle used for transporting patients to a health care facility after injury or illness. Types of ambulances used in the United States i…

    Related ICD-10-CM Codes

    26 rows

    ICD-10-CM CodeDescription
    E11.9Type 2 diabetes mellitus without complications
    E78.5Hyperlipidemia, unspecified
    F32.9Major depressive disorder, single episode, unspecified
    F33.1Major depressive disorder, recurrent, moderate
    G81.90Hemiplegia, unspecified affecting unspecified side
    G82.20Paraplegia, unspecified
    I10Essential (primary) hypertension
    I69.320Aphasia following cerebral infarction
    I69.391Dysphagia following cerebral infarction
    I69.398Other sequelae of cerebral infarction

    Showing 1–10 of 26

    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

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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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