Summary & Overview
HCPCS G9091: Rectal Cancer Disease Status, Invasive Adenocarcinoma
HCPCS Level II code G9091 captures a specific disease-status assessment for rectal cancer: invasive rectal adenocarcinoma initially staged as t3, n0, m0, with no evidence of progression, recurrence, or metastasis. It is designated for use in a Medicare-approved demonstration project and supports standardized reporting of baseline extent of disease before any neo-adjuvant therapy. Nationally, a precise code for this clinical scenario matters for program evaluation, quality measurement, and consistent documentation across oncology care settings.
Key payers relevant to national analyses include Aetna, Blue Cross Blue Shield plans, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code's clinical scope and service context, typical venue of care, and the policy context tied to demonstration project use. The publication will also present available benchmarks where present, discuss common billing modifiers and coding considerations, and summarize related billing and clinical implications for oncology service lines. Data elements not provided in the input are noted as unavailable; this report focuses on the provided description and national-level relevance rather than state-level program specifics.
Billing Code Overview
HCPCS Level II code G9091 documents disease status for rectal cancer, limited to invasive cancer with adenocarcinoma as the predominant cell type. The description specifies that the extent of disease was initially established as t3, n0, m0 (prior to neo-adjuvant therapy, if any) and that there is no evidence of disease progression, recurrence, or metastases. This code is intended for use in the context of a Medicare-approved demonstration project.
Service Type: Oncology — disease status reporting
Typical Site of Service: Hospital outpatient or oncology clinic, where staging and treatment planning or follow-up assessments for rectal cancer are performed.
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with biopsy-proven rectal adenocarcinoma is evaluated in a multidisciplinary oncology clinic prior to neoadjuvant therapy. Staging workup including pelvic MRI and CT chest/abdomen/pelvis establishes initial extent of disease as T3, N0, M0. The patient has no clinical or radiographic evidence of progression, recurrence, or distant metastases. The clinical workflow includes history and physical, review of imaging and pathology, tumor board discussion, documentation of baseline disease status for a Medicare-approved demonstration project, and formulation of a treatment plan (which may include neoadjuvant chemoradiation followed by surgery or primary surgery depending on multidisciplinary recommendation). The documented disease status T3 N0 M0 is recorded prior to initiation of any neo-adjuvant therapy and used as the baseline for outcome tracking within the demonstration project. Typical site of service is an outpatient oncology clinic or hospital outpatient department within academic or community cancer centers. Typical service type is disease status documentation and staging assessment for rectal cancer for reporting within a Medicare-approved quality demonstration.
Coding Specifications
| Modifier | Description | When to Use |
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