HCPCS G9072: Invasive Breast Cancer, ER/PR Negative Disease Status - OpenPayer

Summary & Overview

HCPCS G9072: Invasive Breast Cancer, ER/PR Negative Disease Status

HCPCS Level II code G9072 denotes a disease-status classification for invasive female breast cancer characterized by adenocarcinoma histology, early-stage disease (stage I, stage IIA–IIB, or T3, N1, M0), and negative estrogen and progesterone receptors, with no evidence of progression, recurrence, or metastasis. The code is designated for use within a Medicare-approved demonstration project and captures a precise clinical subgroup of breast cancer important for trial enrollment, reporting, and outcome measurement. Nationally, a standardized code for this disease status supports consistent reporting across oncology providers and demonstrations that inform Medicare policy.

Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find benchmarks and policy context related to the code’s intended use in demonstration projects, an explanation of the clinical criteria embedded in the code description, and guidance on typical sites of service and service type for billing and reporting purposes. The summary outlines limitations where supplemental data elements (such as associated taxonomies, ICD-10 mappings, and related codes) are not provided in the input.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9072HCPCS Level IIoncologybreast cancerdisease statusearly-stage breast canceradenocarcinomaER negativePR negative

Billing Code Overview

HCPCS Level II code G9072 identifies a specific oncology disease-status classification for female breast cancer. The description specifies invasive female breast cancer with adenocarcinoma as the predominant cell type, limited to early-stage disease (stage I, stage IIA–IIB, or T3, N1, M0) and estrogen receptor (ER) and progesterone receptor (PR) negative, with no evidence of disease progression, recurrence, or metastases. The code is intended for use within a Medicare-approved demonstration project.

Service type: Oncology disease-status classification and reporting.

Typical site of service: Oncology clinic or cancer center outpatient setting, or other clinical settings where disease-status assessments and reporting for breast cancer are performed, including facilities participating in Medicare demonstration projects.

Clinical & Coding Specifications

Clinical Context

A 58-year-old female with a prior diagnosis of invasive female breast cancer presents to a participating Medicare-approved demonstration project clinic for routine disease-status assessment. Her tumor was originally staged as Stage IIA (T2 N0 M0) with adenocarcinoma predominant histology and estrogen receptor (ER) and progesterone receptor (PR) negative status. She completed definitive local therapy (lumpectomy with sentinel lymph node biopsy and radiotherapy) and systemic chemotherapy, and currently has no clinical or radiographic evidence of progression, recurrence, or metastasis. The visit consists of a focused oncology disease-status evaluation including review of symptoms, physical exam of the breasts and regional nodes, review of recent imaging (mammogram +/- diagnostic views, chest imaging if indicated), review of pathology and receptor status, and documentation of current surveillance plan. Relevant documentation includes staging, receptor status (ER/PR negative), prior treatments, current performance status, and confirmation of no evidence of disease progression. Typical workflow: oncology nurse schedules visit and obtains recent imaging reports; medical oncologist or breast surgical oncologist performs the clinical assessment, documents disease-free status and surveillance plan, and completes billing for the demonstration project service using G9072 with appropriate modifier(s). Typical site of service is an outpatient oncology clinic or breast center within a hospital outpatient department or freestanding oncology practice. Typical patient scenario involves routine surveillance visits at regular intervals following completion of active treatment, with coordination of imaging and lab results as needed.

Coding Specifications

Modifier	Description	When to Use

HCPCS G9924: Documentation of Medical Reason to Omit Safety Screening

HCPCS-G9824-ENDOMETRIAL-SAMPLING-OR-HYSTEROSCOPY-WITH-BIOPSY-NO-DOCUMENTED-RESULTS

HCPCS G9824: Endometrial Sampling or Hysteroscopy with Biopsy, Results Not Documented

HCPCS-G0514-PROLONGED-PREVENTIVE-SERVICE-ADDITIONAL-30-MINUTES

HCPCS G0514: Prolonged Preventive Service, Additional 30 Minutes

HCPCS-G2213-ED-INITIATION-OPIOID-USE-DISORDER-MEDICATION

HCPCS G2213: ED Initiation of Medication for Opioid Use Disorder

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

HCPCS G9226: Comprehensive Foot Examination, Sensory and Vascular Assessment

HCPCS-G9067-NON-SMALL-CELL-LUNG-CANCER-UNKNOWN-STAGING

HCPCS G9067: Non-Small Cell Lung Cancer, Staging Unknown

HCPCS-G0038-CLINICIAN-DETERMINES-NO-REFERRAL

HCPCS G0038: Clinician Determines Patient Does Not Require Referral

HCPCS-G8652-HIP-IMPAIRMENT-RESIDUAL-SCORE-NEGATIVE

HCPCS G8652: Hip Impairment Residual Score < 0

HCPCS-G2204-SCREENING-COLONOSCOPY-AGE-45-85

HCPCS G2204: Screening Colonoscopy for Patients Aged 45–85

HCPCS-G9917-ADVANCED-STAGE-DEMENTIA-CAREGIVER-KNOWLEDGE-LIMITED

HCPCS G9917: Advanced Stage Dementia with Limited Caregiver Knowledge

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`00`	No modifier or default service indicator	Use as the primary claim when no specific billing modifier applies.
`22`	Increased procedural services	Use when additional, medically necessary work beyond typical disease-status assessment is documented (e.g., extended counseling, complex decision-making).
`23`	Unusual anesthesia	Not commonly used for this outpatient clinical assessment; include only if unexpected anesthesia unrelated to planned procedure occurred.
`52`	Reduced services	Use when the full service was not provided and this reduction is documented (e.g., patient left before completion).
`53`	Discontinued procedure	Use when the assessment or planned portion of service was started but discontinued for documented clinical reasons.
`54`	Surgical care only	Use when the billing relates only to surgical components and another provider bills postoperative care (rare for this code).
`55`	Postoperative management only	Use when only postoperative follow-up is provided by the billing provider and another billed the surgical encounter.
`56`	Preoperative management only	Use when only preoperative assessment is billed separately.
`62`	Two surgeons	Use when two surgeons of different specialties share surgical management responsibilities and documentation supports distinct work (rare for disease-status visits).
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for Medicare patients	Use when an advanced practice clinician provides services under Medicare rules and appropriate supervision applies.
`CO`	Services related to impairment or disability	Use when the service is related to a condition due to a work-related illness covered by a commercial worker's compensation payer requiring distinct billing.
`CQ`	Service furnished under a qualified clinical trial	Use when the patient is enrolled in a qualifying clinical trial and the visit is part of trial care.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures (when applicable)	Use only if anesthesia supervision applies to an associated procedure.
`QX`	CRNA service with medical direction	Use when a CRNA performs anesthesia with physician direction for any associated procedure.
`QY`	Anesthesiologist medically directs one CRNA	Use when documented anesthesia medical direction applies.

Taxonomy Code	Specialty	Notes
`208000000X`	Medical Oncology	Primary specialty for systemic disease evaluation and surveillance.
`207Q00000X`	Surgical Oncology / General Surgery (Breast Surgery)	Specialty for surgical management and postoperative surveillance of breast cancer.
`364S00000X`	Nurse Practitioner	Common provider for follow-up visits and survivorship care in oncology clinics.
`363L00000X`	Physician Assistant	Frequently documents and bills follow-up disease-status visits under supervising physician.
`2086S0102X`	Hematology-Oncology	Combined specialty that may follow breast cancer patients for systemic therapy and surveillance.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C50.911`	Malignant neoplasm of unspecified site of right female breast	Represents invasive breast cancer diagnosis used for disease-status monitoring and billing.
`C50.912`	Malignant neoplasm of unspecified site of left female breast	Represents invasive breast cancer diagnosis for left-sided disease surveillance.
`C50.919`	Malignant neoplasm of unspecified site of breast, unspecified	Used when side is not specified in documentation but invasive disease is present and being monitored.
`Z85.3`	Personal history of malignant neoplasm of breast	Captures surveillance context when the patient has a history of treated breast cancer with current no evidence of disease.
`Z08`	Encounter for follow-up examination after completed treatment for malignant neoplasm	Used to indicate follow-up surveillance visits after completion of definitive cancer therapy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M code used for routine surveillance visits when evaluation and management are billed in addition to or instead of demonstration project reporting.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Use for more complex surveillance visits with moderate complexity medical decision-making or extended counseling.
`77067`	Screening mammography, bilateral (2-view study of each breast)	Frequently performed or reviewed as part of breast cancer surveillance; imaging reviewed during disease-status assessment.
`77065`	Diagnostic mammography, including CAD when performed; unilateral or bilateral	Used when targeted diagnostic imaging is required for suspicious findings identified during follow-up.
`88305`	Level IV surgical pathology, gross and microscopic examination	Used when tissue biopsy is obtained for any suspicious recurrence identified during surveillance and pathology is processed.
`96372`	Therapeutic, prophylactic, or diagnostic injection (e.g., supportive medications)	May be used for administration of supportive medications during clinic visits if applicable.

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