Summary & Overview

HCPCS G8941: Elder Maltreatment Screen Positive, No Follow-Up Plan

HCPCS Level II code G8941 denotes a documented positive elder maltreatment screen in which a follow-up care plan was not recorded because the patient was documented as not eligible for follow-up at the encounter. This code formalizes documentation for clinicians and payers when screening identifies possible abuse, neglect, or exploitation but follow-up actions are not pursued at that time.

Key payers in national analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Coverage and reporting practices for elder maltreatment screening affect quality measurement, care coordination, and documentation workflows across outpatient clinics, primary care, and emergency departments.

Readers will learn what G8941 represents clinically and administratively, which settings typically use the code, and what information is commonly documented alongside a positive screen with no follow-up plan. The publication also summarizes payer considerations and common modifier usage (listed elsewhere), and highlights reporting and coding implications relevant to quality measurement and care management. Data not available in the input for taxonomies, ICD-10 pairings, or related service-line benchmarks are noted elsewhere in the publication.

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Billing Code Overview

HCPCS Level II code G8941 indicates an elder maltreatment screen documented as positive when a follow-up plan was not documented, with documentation that the patient is not eligible for a follow-up plan at the time of the encounter. This code captures a positive screening result for elder abuse, neglect, or exploitation coupled with documentation that no follow-up plan was appropriate or possible during that visit.

Service Type: Screening and documentation of elder maltreatment with eligibility determination

Typical Site of Service: Outpatient clinic, primary care setting, emergency department, or other ambulatory care sites where screening and documentation occur

Clinical & Coding Specifications

Clinical Context

A 78-year-old female presents to a primary care clinic for a routine Medicare wellness visit. During the encounter the clinician performs an elder maltreatment screening using a validated screening tool. The screen is documented as positive for possible neglect and financial exploitation. The clinician discusses immediate safety concerns, attempts to contact adult protective services and the patients identified caregiver, and documents the conversation in the medical record. The clinician determines that a formal follow-up plan (such as referral to social work, safety planning, or concrete services) cannot be implemented at the time of the visit because the patient refuses additional services and lacks immediate capacity for placement. The clinician documents that the patient is not eligible for a follow-up plan at the time of the encounter and bills G8941 to indicate a positive screen with no follow-up plan documented and patient not eligible for follow-up at that encounter.

Typical workflow:

Patient registration and brief psychosocial history.
Clinician administers elder maltreatment screening tool and documents results.
Positive screen prompts clinical assessment, risk discussion, and attempted linkage to resources.
If follow-up plan cannot be initiated and the clinician documents patient not eligible for follow-up, code G8941 is reported.
Relevant documentation includes the screening tool result, notes on safety assessment, attempts to arrange services, and rationale that the patient was not eligible for follow-up at that encounter.

Typical site of service: outpatient primary care clinic, geriatric clinic, or outpatient behavioral health integrated in primary care. Emergency department or inpatient settings may also document screening but billing and reporting may vary by payor.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when there is a significantly greater level of work or complexity in counseling, documentation, or coordination beyond typical screening (rare for `G8941`).
`23`	Unusual anesthesia	Not typically applicable; include only if screening occurred during an encounter with anesthesia that was unrelated to the screening.
`52`	Reduced services	Use if the screening service was partially performed or truncated and not fully completed.
`53`	Discontinued procedure	Use if the screening was started but discontinued due to patient condition or inability to complete.
`54`	Surgical care only	Not applicable to this screening service; generally not used.
`55`	Postoperative management only	Not applicable to this service.
`56`	Preoperative management only	Not applicable to this service.
`62`	Two surgeons	Not applicable; not typically used for screening services.
`AS`	Ambulatory surgical center (ASC) payment adjustment	Use only if billing rules require reporting of the ASC place of service for the encounter; rarely applicable to `G8941`.
`CO`	Cast application	Not applicable to this screening service.
`CQ`	Telehealth originating site — patient location	Use when the patient is at an originating telehealth site that requires this modifier per payor rules.
`FX`	Indicates a fracture care modifier	Not applicable to this screening service.
`FY`	Indicates physician service in a facility	May be used per specific payor rules to indicate facility physician services; check payor guidance.
`QK`	Medical direction of two, three, or four assistants at surgery	Not applicable to this screening service.
`QX`	Certified registered nurse anesthetist (CRNA) service	Not applicable to this screening service.
`QY`	Medical direction of one certified registered nurse anesthetist by a physician	Not applicable to this screening service.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who perform elder maltreatment screening during routine visits.
`207R00000X`	Internal Medicine	Internists and geriatricians commonly perform screening and document follow-up decisions.
`207G00000X`	Geriatric Medicine	Specialists focusing on older adults who perform detailed assessments and coordinate services.
`208000000X`	Psychiatry & Neurology	Behavioral health clinicians and consult-liaison providers involved when cognitive impairment or abuse-related mental health issues are present.
`246700000X`	Social Worker	Licensed clinical social workers who document care coordination and resource referrals; may not bill but are part of the workflow.

ICD-10 Code	Description	Clinical Relevance
`Z62.820`	Parent-child relational problem	Social risk factors that may coexist with elder maltreatment concerns and prompt screening.
`T74.11XA`	Adult physical abuse, confirmed, initial encounter	Represents confirmed physical abuse in adults; a positive screen may lead to further evaluation and diagnosis.
`T76.11XA`	Adult physical abuse, suspected, initial encounter	Used when screening or evaluation indicates suspected abuse but confirmation is pending.
`T74.91XA`	Adult neglect or abandonment, confirmed, initial encounter	Relevant when screening suggests neglect that is later confirmed.
`T76.91XA`	Adult neglect or abandonment, suspected, initial encounter	Often used when a screening is positive for neglect but investigation is incomplete.

CPT Code	Description	Relationship to This Procedure
`99406`	Smoking and tobacco-use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Example of a brief counseling E/M–adjacent service that may be delivered in the same visit when behavioral interventions are provided after a positive screen.
`99407`	Smoking and tobacco-use cessation counseling, intensive, greater than 10 minutes	Represents longer counseling services that could be billed if extended counseling occurs in response to a positive screen and payor allows concurrent billing.
`99384`	Initial comprehensive preventive medicine evaluation and management of an individual, new patient; 45–64 years	Preventive visit codes often accompany screening activities; for established older adults use the appropriate age-based preventive code.
`99397`	Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; 65 years and older	Common preventive visit during which elder maltreatment screening may be performed and documented.
`99499`	Unlisted evaluation and management service	May be used in exceptional billing circumstances when no specific code describes a concurrent nonstandard service related to screening follow-up, per payor rules.

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