Summary & Overview

HCPCS G9079: Prostate Cancer Disease Status, Adenocarcinoma, T3b–T4/N1

HCPCS Level II code G9079 identifies a disease-status classification for prostate cancer limited to adenocarcinoma as the predominant cell type, covering stages T3b–T4 (any N) and any T with N1 at diagnosis when there is no evidence of progression, recurrence, or metastases. The code is designated for use in a Medicare-approved demonstration project, signaling a targeted reporting and eligibility construct rather than a routine billing pathway. Nationally, this distinction matters for coverage policy, clinical registry reporting, and demonstration-project evaluations of care patterns for locally advanced prostate cancer.

Key payers addressed in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on the clinical definition embedded in the code, the typical service setting for disease-status documentation, and how the code is used within demonstration frameworks. The publication outlines benchmark considerations, relevant policy implications for payer coverage and demonstration projects, and clinical context for staging and documentation that affect coding and reporting. Where available, the report highlights payer alignment and gaps in coverage rules, along with areas where demonstration-project designation may influence claim adjudication and data collection. Data not available in the input has been noted for elements such as associated taxonomies, specific ICD-10 pairings, and related codes.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9079HCPCS Level IIprostate canceradenocarcinomaoncology disease statusdemonstration projectdisease stagingoutpatient oncologycoding and reporting

Billing Code Overview

HCPCS Level II code G9079 describes a specific oncology disease-status classification for prostate cancer, limited to adenocarcinoma as the predominant cell type. The code captures disease stages T3b–T4, any N, and any T with N1 at diagnosis, provided there is no evidence of disease progression, recurrence, or metastases. This designation 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 hospital outpatient setting where disease-status assessment and documentation occur, including tumor board or multidisciplinary evaluation settings.

Clinical & Coding Specifications

Clinical Context

A 68-year-old man with a history of prostate adenocarcinoma (predominant cell type adenocarcinoma) initially staged at clinical T3bN0M0 undergoes periodic disease-status assessment as part of a Medicare-approved demonstration project. He completed primary therapy (radical prostatectomy and salvage radiotherapy) and currently has no evidence of disease progression, recurrence, or distant metastases. The oncology team documents clinical exam, prostate-specific antigen (PSA) trend review, imaging review (if performed), and multidisciplinary care discussion to confirm stable disease (T3b–T4, any N; or any T, N1 at diagnosis) without progression. The service described by G9079 is reported when documenting disease status for prostate cancer limited to adenocarcinoma as the predominant cell type in the context of the demonstration project.

Workflow:

Initial encounter: review of prior pathology, staging, treatment history, and recent PSA values.
Focused clinical assessment: genitourinary history, digital rectal exam, assessment for local symptoms (urinary obstruction, hematuria), and review of systems relevant to potential progression.
Diagnostic reconciliation: review of prior imaging (pelvic MRI, CT, bone scan, or PSMA PET if available) and laboratory data to confirm absence of progression or metastasis.
Documentation: clinician documents disease status as stable/no evidence of progression and the specific staging context (T3b–T4 any N or any T with N1 at diagnosis), cites adenocarcinoma predominance, and records participation in the Medicare-approved demonstration project.
Billing: use of G9079 to report the disease-status assessment for the demonstration project; appropriate CPT codes for visits, imaging, or labs billed separately; applicable modifiers attached per payer rules.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier — full procedure/service	Use when no special circumstances or modifiers apply to the `G9079` claim.
`22`	Increased procedural services	Use when documentation supports substantially greater work, time, or complexity for the disease-status assessment beyond typical expectations.
`23`	Unusual anesthesia — medically necessary	Use only if an unexpected anesthesia complication or unusual anesthesia was required during a procedure billed in conjunction with assessment services.
`52`	Reduced services	Use when the assessment or service was partially reduced or not fully performed and documentation supports reduced work.
`53`	Discontinued procedure	Use if an intended procedure related to the disease-status evaluation was started but discontinued for substantive, documented reasons.
`54`	Surgical care only	Use when the reporting provider billed only for the surgical component of a related procedure; rarely applicable to `G9079` but used if surgical component is separately billed.
`55`	Postoperative management only	Use when only postoperative disease-status follow-up is billed separate from the original procedure.
`56`	Preoperative management only	Use when only preoperative evaluation related to disease-status is billed separate from the procedure.
`62`	Two surgeons	Use when two surgeons of different specialties share responsibility for a related procedure documented alongside disease-status assessment.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist service	Use to indicate services furnished by a physician assistant, nurse practitioner, or clinical nurse specialist when billing rules require the `AS` modifier for Medicare demonstration reporting.
`CO`	Out-of-area or noncontracted provider (for Workers' Compensation)	Use when the service is billed under workers' compensation or similar payor rules requiring `CO`.

Taxonomy Code	Specialty	Notes
`2084P0800X`	Hematology & Oncology	Medical oncology clinicians managing prostate cancer disease-status assessments and demonstrating participation in projects.
`207RA0000X`	Radiation Oncology	Radiation oncologists who perform follow-up assessments after radiotherapy for prostate cancer.
`208000000X`	Urology	Urologists performing prostate cancer staging, clinical exams, and follow-up.
`363L00000X`	Nuclear Medicine	Specialists interpreting advanced imaging (bone scan, PSMA PET) used in disease-status evaluation.
`207L00000X`	Diagnostic Radiology	Radiologists interpreting pelvic MRI, CT, and other imaging used to confirm no progression.

ICD-10 Code	Description	Clinical Relevance
`C61`	Malignant neoplasm of prostate	Primary diagnosis indicating prostate cancer for which disease-status `G9079` applies.
`D07.5`	Carcinoma in situ of prostate	Relevant for history of prostate neoplasia; may appear in problem list though `G9079` is specific to adenocarcinoma predominance.
`N40.0`	Benign prostatic hyperplasia with urinary obstruction	Common comorbidity impacting symptoms and evaluation during follow-up visits.
`R97.2`	Elevated prostate specific antigen (PSA)	Used when PSA elevation prompts disease-status assessment or surveillance.
`Z85.46`	Personal history of malignant neoplasm of prostate	Used in survivorship documentation and long-term disease-status follow-up.

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 visit level for routine disease-status follow-up visits documenting stable prostate cancer and PSA review.
`99214`	Office or other outpatient visit for established patient, typically 25 minutes	Use when the evaluation requires moderate complexity decision-making or extended counseling regarding disease status and management.
`78607`	Bone imaging, planar, whole body, static imaging, each additional view	Used when bone scan imaging is performed to evaluate for metastases as part of disease-status assessment (imaging billed separately).
`72195`	Magnetic resonance imaging, pelvis; without contrast material	Pelvic MRI frequently used to evaluate local recurrence or extraprostatic extension when confirming disease status.
`78320`	Bone imaging, single-photon emission computed tomography (SPECT)	Employed when SPECT is obtained to better localize suspected bone metastasis during assessment of disease status.
`84153`	Prostate specific antigen (PSA); total	Laboratory test commonly performed and reviewed as part of the disease-status assessment for prostate cancer.

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