G8736 LDL-C <100 mg/dL HCPCS Reimbursement

HCPCS Level II code G8736 denotes documentation that a patient's most recent low-density lipoprotein cholesterol (LDL-C) is less than 100 mg/dL. This code is used as part of clinical quality measurement and reporting for cardiovascular risk management and lipid control. Nationally, tracking LDL-C levels is central to preventive cardiology and population health programs because LDL-C control is linked to reduced risk of atherosclerotic cardiovascular disease and influences quality reporting and value-based payment metrics.

Key payers relevant to this code include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for G8736, the payer landscape that commonly engages with LDL-C quality measures, and the types of benchmarks and reporting implications associated with LDL-C documentation. The publication summarizes how the code is used for laboratory result reporting and quality measurement in outpatient and primary care settings, outlines typical sites of service, and highlights where additional data is required for coding detail and claim submission specifics.

This piece is intended for billing managers, quality leaders, and clinicians seeking a concise reference on the purpose and national relevance of HCPCS Level II code G8736 and what stakeholders generally monitor when this measure is reported.

Billing Code Overview

HCPCS Level II code G8736 indicates Most current LDL-C <100 mg/dL. This measure reflects documentation that a patient's most recent low-density lipoprotein cholesterol (LDL-C) level is below 100 milligrams per deciliter. The service type is laboratory result reporting / clinical quality measure tracking, and the typical site of service is ambulatory outpatient clinics and primary care settings where lipid testing and chronic disease management occur.

Data not available in the input.

Clinical Context

A primary care patient with known hyperlipidemia attends a routine follow-up visit to evaluate cardiovascular risk control. The clinician documents current medications and recent laboratory results. A fasting or non-fasting lipid panel has been performed within the measurement period; the most recent low-density lipoprotein cholesterol result is reviewed and recorded. The quality measure represented by G8736 is abstracted from the chart: it is met when the most recent LDL-C is documented as <100 mg/dL. Typical workflow includes ordering or obtaining the lipid panel, entering the result into the problem list or vitals/labs flowsheet, and coding the encounter for quality reporting. Typical sites of service include outpatient primary care clinics, cardiology clinics, and ambulatory laboratory facilities. A common patient scenario: a 62-year-old patient with a history of coronary artery disease and hyperlipidemia on statin therapy presents for routine follow-up; a lipid panel obtained two weeks prior shows LDL-C 88 mg/dL, which is documented in the chart and used for quality reporting under G8736.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure	Use when an E/M visit is rendered in addition to procedures or services on the same day.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary providers ordering and reviewing lipid panels in outpatient care.
`207R00000X`	Internal Medicine	Common primary care specialty managing hyperlipidemia and LDL goals.
`207RR0500X`	Cardiology	Specialists managing lipid targets for patients with coronary artery disease.
`2083P0800X`	Nurse Practitioner	Advanced practice providers performing visits and ordering labs.
`163W00000X`	Clinical Laboratory	Providers and facilities performing the lipid panel testing.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E78.0`	Pure hypercholesterolemia	Primary diagnosis associated with elevated LDL-C and indication for lipid monitoring.
`E78.5`	Hyperlipidemia, unspecified	General diagnosis used for patients requiring lipid panel monitoring, including LDL-C.
`I25.10`	Atherosclerotic heart disease of native coronary artery without angina pectoris	Secondary prevention population where LDL-C <100 mg/dL is an important quality target.
`I10`	Essential (primary) hypertension	Common comorbidity increasing cardiovascular risk and prompting lipid management.
`E78.2`	Mixed hyperlipidemia	Patients with combined lipid abnormalities monitored with lipid panels that include LDL-C.
`E78.1`	Pure hyperglyceridemia	Associated dyslipidemia that often coexists with LDL abnormalities and prompts lipid testing.
`E78.49`	Other hyperlipidemia	Additional hyperlipidemia diagnoses that may require LDL-C monitoring for risk management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`80061`	Lipid panel (includes total cholesterol, HDL, and triglycerides; LDL may be calculated)	Common laboratory panel ordered to obtain LDL-C value used to meet `G8736`.
`82465`	Cholesterol, direct, LDL cholesterol	Used when direct LDL-C measurement is performed rather than calculation; provides the specific LDL value counted for `G8736`.
`36415`	Collection of venous blood by venipuncture	Performed to obtain the blood sample for the lipid panel or direct LDL test.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Typical E/M visit during which LDL results are reviewed and care decisions are documented for quality reporting.
`99406`	Smoking and tobacco-use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Common preventive counseling service provided in the same visit for patients with cardiovascular risk factors; often documented alongside lipid management.

OpenPayer

Summary & Overview

HCPCS G8736: Most Current LDL-C <100 mg/dL