G9075 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS G9075: Metastatic Invasive Female Breast Cancer, Adenocarcinoma

HCPCS Level II code G9075 identifies disease-status reporting for invasive female breast cancer with adenocarcinoma as the predominant cell type in patients who are M1 at diagnosis, metastatic, locally recurrent, or progressive. The code is intended for use within a Medicare-approved demonstration project and captures a specific clinical scenario relevant to oncology care coordination and program evaluation. Nationally, precise coding for advanced breast cancer supports quality measurement, program participation, and appropriate documentation for demonstration initiatives.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical definition and service context, guidance on typical sites of service, and a summary of what to expect when this code is encountered in billing or program workflows. The publication also outlines benchmarking and policy-relevant considerations where available, and highlights gaps in publicly provided data.

This summary equips clinicians, coders, and policy analysts with the clinical context and national relevance of G9075, clarifies where the service is typically delivered, and flags that the code is tied to a Medicare demonstration project rather than routine fee-for-service reporting.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9075HCPCS Level IIbreast cancermetastatic diseaseoncologydisease statusadenocarcinomademonstration project

Billing Code Overview

HCPCS Level II code G9075 describes oncology disease status for invasive female breast cancer (excluding ductal carcinoma in situ) where adenocarcinoma is the predominant cell type and the patient is M1 at diagnosis, metastatic, locally recurrent, or progressive. The code is specified for use in a Medicare-approved demonstration project.

Service type: Oncology disease status assessment and reporting
Typical site of service: Oncology clinic or hospital outpatient setting where disease-status evaluations and reporting related to metastatic or recurrent breast cancer are performed

Clinical & Coding Specifications

Clinical Context

A 58-year-old woman with a prior diagnosis of invasive adenocarcinoma of the left breast presents to a multidisciplinary oncology clinic for enrollment in a Medicare-approved demonstration project tracking disease status and outcomes. She was staged M1 at diagnosis with known bone and liver metastases and has received systemic therapy (endocrine therapy and targeted agents) and palliative radiation to a spinal lesion. The oncology nurse practitioner documents current symptoms, performance status, recent imaging (CT chest/abdomen/pelvis and bone scan), laboratory results (CBC, CMP, tumor markers), and records any changes in systemic therapy or supportive care.

Workflow steps:

Referral and eligibility verification for the Medicare demonstration project.
Initial oncology visit: history of present illness, review of systems, medication reconciliation, and physical exam focused on sites of known metastatic disease.
Ordering and review of imaging (CT, MRI, PET as indicated) and labs to determine current disease status (stable, progressive, or recurrent).
Multidisciplinary discussion and documentation of disease status in the medical record and project-specific data capture forms.
Communication of findings and next-step treatment plan to the patient; scheduling of follow-up and any necessary supportive or palliative services.
Billing using G9075 to report disease status for invasive female breast adenocarcinoma (M1/metastatic/locally recurrent/progressive) within the Medicare demonstration project context.

Coding Specifications

HCPCS G8868: First Course Anti-TNF Therapy Initiation

HCPCS-G9739-ORTHOPEDIC-FUNCTIONAL-STATUS-UNABLE-TO-COMPLETE

HCPCS G9739: Orthopedic Functional Status Unable to Complete

HCPCS-G9351-PARANASAL-SINUS-CT-REPEAT-WITHIN-90-DAYS

HCPCS G9351: Repeat CT of Paranasal Sinuses Within 90 Days

HCPCS-G9841-RAS-TESTING-NOT-PERFORMED-BEFORE-ANTI-EGFR-THERAPY

HCPCS G9841: Ras (KRAS and NRAS) Mutation Testing Not Performed Before Anti-EGFR Therapy

HCPCS-G6046-DIHYDROMORPHINONE-MEDICATION-ADMINISTRATION

HCPCS G6046: Dihydromorphinone medication administration

HCPCS-G8722-PATHOLOGY-REPORT-PT-PN-GRADE-NOT-INCLUDED-JUSTIFICATION

HCPCS G8722: Pathology Report — Pt/Pn/Grade Not Included Justification

HCPCS-G0433-HIV-ELISA-SCREENING-ANTIBODY-DETECTION

HCPCS G0433: HIV-1/HIV-2 Antibody Screening by ELISA

HCPCS-G8808-TRANSABDOMINAL-TRANSVAGINAL-ULTRASOUND-NOT-PERFORMED

HCPCS G8808: Trans-abdominal or Trans-vaginal Ultrasound Not Performed

HCPCS-G0558-ADVANCED-PRIMARY-CARE-MANAGEMENT

HCPCS G0558: Advanced Primary Care Management for Complex Chronic Patients

HCPCS-G8874-EXCISED-TISSUE-WITHOUT-INTRAOPERATIVE-IMAGING-CONFIRMATION

HCPCS G8874: Excised Tissue Without Intraoperative Imaging Confirmation

Showing 1–10 of 1996

Modifier	Description	When to Use
`00`	Default/No modifier specified	Use when no specific modifier applies and standard reporting is intended.
`22`	Increased procedural services	Use when work required is substantially greater than typical for documentation related to disease-status assessment in complex metastatic cases.
`23`	Unrelated evaluation and management service by same physician during postoperative period	Use if an unrelated E/M is provided during the same visit while documenting disease status for the demonstration.
`52`	Reduced services	Use when the disease-status assessment service is partially reduced or abbreviated.
`53`	Discontinued procedure	Use if the planned disease-status assessment encounter was started but discontinued for patient safety reasons.
`54`	Surgical care only	Rarely applicable; use only if procedure-related surgical care is billed separately from the disease-status documentation.
`55`	Postoperative management only	Use if only follow-up management after a procedure is provided during the disease-status visit.
`56`	Preoperative management only	Use if the visit consisted solely of preoperative care when a surgical intervention for metastatic disease is planned.
`62`	Two surgeons	Use when two surgeons share responsibility for surgical aspects documented in the disease-status encounter.
`AS`	Physician is the primary surgeon	Use when reporting the primary surgeon’s documentation within the demonstration project encounter.
`CO`	Catastrophic/Disability-based payer responsibility	Use when another payer, such as a state catastrophic fund, is responsible for services documented while Medicare demonstration reporting uses `G9075`.
`CQ`	Service furnished by a resident without an attending during Graduate Medical Education	Use when a resident documents the disease-status assessment without direct attending involvement in a qualifying setting.
`QK`	Medical direction of two, three, or four concurrent procedures involving qualified individuals	Use when medical direction applies to concurrent services documented during the same visit.
`QY`	Medical direction of one qualified individual by a physician	Use when the physician medically directs a single qualified individual providing services documented in the encounter.

Taxonomy Code	Specialty	Notes
`2086P0207X`	Medical Oncology	Primary specialty managing systemic therapy and disease-status assessment for metastatic breast cancer.
`207RP1001X`	Hematology/Oncology	Common combined specialty providing longitudinal cancer care and participation in demonstration projects.
`207L00000X`	Radiation Oncology	Provides palliative radiation and documents local control and disease progression status.
`163WL0500X`	Nurse Practitioner	Oncology nurse practitioners frequently perform evaluation, documentation, and care coordination for disease-status reporting.
`363A00000X`	Internal Medicine — Hospitalist	Hospital-based physicians involved when inpatient disease-status assessments or complications arise.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C50.912`	Malignant neoplasm of unspecified site of left female breast	Primary invasive breast cancer diagnosis commonly associated with metastatic disease-status reporting.
`C50.911`	Malignant neoplasm of unspecified site of right female breast	Primary invasive breast cancer of the right breast for disease-status documentation when right-sided disease is present.
`C79.51`	Secondary malignant neoplasm of bone	Common metastatic site in M1 breast cancer; relevant when documenting progression or response.
`C78.7`	Secondary malignant neoplasm of liver and intrahepatic bile duct	Liver metastases are frequent in metastatic breast adenocarcinoma and affect disease-status assessment.
`C79.82`	Secondary malignant neoplasm of adrenal gland	Less common but clinically relevant metastatic site to document when present.
`C50.912`	Malignant neoplasm of left female breast, invasive adenocarcinoma — recurrent/progressive disease context	Used to indicate ongoing invasive breast cancer status in the demonstration project.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, moderate to high complexity	Commonly used for comprehensive outpatient disease-status assessment visits that include review of imaging and management decisions before billing the demonstration project code.
`77427`	Radiation treatment management, medical physician; weekly management	Used when ongoing radiation therapy is part of management for metastatic lesions and disease status is documented concurrently.
`88360`	Immunohistochemistry, per specimen; initial single antibody stain	Used when biopsy or tissue testing is performed to confirm receptor status or histology in recurrent/metastatic disease.
`96365`	Intravenous infusion, therapeutic, prophylactic, or diagnostic; initial, up to 1 hour	Used when systemic therapy infusions (chemotherapy) occur and disease-status documentation is performed in the same clinical episode.
`76942`	Ultrasonic guidance for needle placement	Used when image-guided biopsies of metastatic sites are performed as part of restaging and disease-status determination.

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