HCPCS G8940: Positive Depression Screening, Follow-Up Not Completed - OpenPayer

Summary & Overview

HCPCS G8940: Positive Depression Screening, Follow-Up Not Completed

HCPCS Level II code G8940 denotes a documented positive depression screening in which a planned follow-up was not completed and the reason for the missed follow-up is recorded. This code is used to capture gaps between screening results and subsequent care actions, providing a standardized way to indicate that screening identified potential depression but planned next steps were not carried out.

Nationally, capturing incomplete follow-up after positive depression screens matters for quality measurement, care coordination, and program evaluation across ambulatory care settings. Payors commonly referenced in analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The code informs payer quality programs, behavioral health integration efforts, and population health initiatives focused on closing care gaps.

Readers will learn what G8940 represents clinically, typical service settings where it is reported, common payer coverage context, and the types of benchmarks and policy considerations that relate to documenting incomplete follow-up after positive depression screens. The publication summarizes how the code is used for tracking screening-to-care transitions, implications for quality reporting, and highlights where input data are not available. Data not provided in the input are noted where relevant.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG8940HCPCS Level IIdepression screeningbehavioral healthcare coordinationquality measurementambulatory care

Billing Code Overview

HCPCS Level II code G8940 documents a positive depression screening when a follow-up plan was not completed, with a documented reason for the incomplete follow-up. The code captures the clinical circumstance in which screening indicates possible depression but the intended next-step care plan (for example, referral, treatment initiation, or monitoring) was not carried out and the reason for that omission is recorded in the patient record.

Service type: Behavioral health screening follow-up documentation

Typical site of service: Outpatient ambulatory settings, including primary care clinics and behavioral health clinics where depression screening is performed and follow-up actions are tracked.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A primary care patient completes a routine depression screening using a standardized tool (for example, PHQ-9) during an outpatient visit. The screening result is documented as positive for depressive symptoms. The clinician documents a reason why the follow-up plan could not be completed during that visit (for example, patient declined, referral appointment unavailable within clinically acceptable timeframe, need for collateral information, or acute medical issue requiring stabilization first). The workflow typically includes: collection of screening tool, documentation of positive result in the medical record, determination that immediate follow-up cannot be completed, documentation of the specific reason for deferring follow-up, and scheduling or planning of a future follow-up action. Typical sites of service are outpatient primary care clinics, community health centers, behavioral health integrated clinics, and federally qualified health centers. Typical patient scenario: a 46-year-old woman presents for chronic disease management; PHQ-9 is positive with moderate depressive symptoms; clinician documents inability to complete warm handoff or mental health referral that day because the patient needs to address transportation barriers and requests follow-up by phone in one week; the reason for not completing the follow-up plan is explicitly recorded in the chart as required for billing code G8940.

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 or other service

HCPCS G2180: Ineligible for Footwear Evaluation, Bilateral Lower-Extremity Amputee

HCPCS-G9890-MDPP-BRIDGE-PAYMENT-FIRST-SESSION-TRANSITION

HCPCS G9890: MDPP One-Time Bridge Payment for Session Transition

HCPCS-G0162-SKILLED-NURSING-PLAN-OF-CARE-MANAGEMENT-HOME-HOSPICE

HCPCS G0162: Skilled RN Plan-of-Care Management in Home Health/Hospice

HCPCS-G4009-HOSPITALISTS-MIPS-SPECIALTY-SET

HCPCS G4009: Hospitalists MIPS Specialty Set

HCPCS-G0426-TELEHEALTH-ED-INITIAL-INPATIENT-CONSULT-50-MIN

HCPCS G0426: Telehealth Consultation, ED or Initial Inpatient (~50 minutes)

HCPCS-LEVEL-II-G8509-POSITIVE-PAIN-ASSESSMENT-NO-FOLLOW-UP-PLAN

HCPCS Level II G8509: Positive Pain Assessment, No Follow-Up Plan

HCPCS-G9689-ELECTIVE-CAROTID-INTERVENTION-INPATIENT-ADMISSION

HCPCS G9689: Elective Carotid Intervention Inpatient Admission

HCPCS-G0451-DEVELOPMENTAL-TESTING-INTERPRETATION-REPORT

HCPCS G0451: Developmental Testing with Interpretation and Report

HCPCS-G9805-HOSPICE-SERVICES-MEASUREMENT-PERIOD

HCPCS G9805: Hospice Services During Measurement Period

HCPCS-G2176-OUTPATIENT-ED-OBSERVATION-TO-INPATIENT-ADMISSION

HCPCS G2176: Outpatient/ED/Observation Visits Resulting in Inpatient Admission

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians commonly perform depression screening and document follow-up planning.
`207R00000X`	Internal Medicine	Internists routinely screen adult patients and document reasons for deferring follow-up.
`208D00000X`	Psychiatry	Psychiatrists may document positive screenings and reasons for delayed follow-up when consulted.
`261QM0800X`	Clinical Social Worker	Behavioral health clinicians and social workers may perform screening and document barriers to follow-up.
`103T00000X`	Clinical Psychologist	Psychologists in integrated care settings may perform standardized screening and document deferred follow-up.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F32.9`	Major depressive disorder, single episode, unspecified	Common diagnosis associated with a positive depression screen indicating possible major depressive disorder requiring follow-up.
`F41.1`	Generalized anxiety disorder	Anxiety disorders frequently co-occur with depressive symptoms and may be identified after a positive screen.
`Z13.89`	Encounter for screening for other disorder	Applicable for documented screening encounters; used when screening is the primary reason for the visit.
`F43.21`	Adjustment disorder with depressed mood	Relevant when depressive symptoms are situational and identified on screening.
`R45.851`	Suicidal ideation	A critical finding that can arise from a positive depression screen and impacts urgency of follow-up; documentation of reason for deferred follow-up must reflect safety considerations when present.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Often delivered in the same primary care visit when behavioral health screening occurs; represents brief counseling that may accompany documentation of a positive depression screen if behavior change counseling is provided.
`99407`	Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes	Similar to `99406` — may be reported when extended behavioral counseling is provided in the same visit following a positive screen.
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory), per standardized instrument	Commonly used to report administration/scoring of a brief depression screening tool such as the PHQ-2 or PHQ-9; often precedes `G8940` documentation.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Frequently the E/M code used when screening is performed during a problem-focused primary care visit; may be billed in the same encounter when clinically appropriate.
`99492`	Initial psychiatric collaborative care management, first 70 minutes in the first calendar month	May be used in integrated behavioral health workflows following a positive screen when collaborative care is initiated; `G8940` documents why immediate follow-up was not completed.
`90832`	Psychotherapy, 30 minutes with patient	May be performed after scheduling or referral following a positive depression screen; not performed the same day if follow-up was deferred and reason documented as required for `G8940`.

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