Summary & Overview
HCPCS G9095: Rectal Cancer Disease Status, Adenocarcinoma Predominant
HCPCS Level II code G9095 represents an oncology disease-status designation for rectal cancer limited to invasive disease with adenocarcinoma as the predominant histology where extent of disease is unknown, staging is in progress, or not listed. The code is noted for use in a Medicare-approved demonstration project and is relevant to oncology providers, hospital billing teams, and payers monitoring demonstration project activity. Nationally, the code matters because it marks encounters tied to staging uncertainty and demonstration-project reporting rather than routine procedural billing.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical meaning, typical service setting, and the payer landscape. The publication outlines what to expect in benchmarking and coverage context, summaries of likely payer considerations, and the clinical context where G9095 applies (staging evaluation for rectal adenocarcinoma). Data not available in the input is noted where applicable; the report does not fabricate missing details. This summary provides a clear starting point for clinicians and billing staff to understand the code’s purpose and national relevance within demonstration-project reporting.
Billing Code Overview
HCPCS Level II code G9095 describes a disease status assessment for rectal cancer when the cancer is limited to invasive disease with adenocarcinoma as the predominant cell type and the extent of disease is unknown, staging is in progress, or not listed. The code is designated for use in a Medicare-approved demonstration project.
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Service type: Oncology disease status assessment
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Typical site of service: Oncology clinic or hospital-based oncology service where staging and diagnostic evaluation occur
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient presents to a tertiary oncology center after a diagnostic colonoscopy identified a rectal mass. Biopsy confirms invasive adenocarcinoma predominating by glandular cells. Clinical staging is incomplete because the patient is undergoing additional imaging (pelvic MRI, chest/abdominal CT) and endorectal ultrasound to determine local extent, nodal status, and distant metastases. The multidisciplinary workflow includes: referral to medical oncology and colorectal surgery, completion of staging studies, pathology confirmation, tumor board review, and enrollment in a Medicare-approved demonstration project for disease-status reporting. The billing code G9095 is used by the treating oncology practice to report disease-status classification for rectal cancer when extent of disease is unknown, staging is in progress, or not listed, within the context of the demonstration project. Typical site of service is an outpatient oncology clinic or hospital outpatient department where staging coordination, patient counseling, and documentation of disease status occur. Common clinical actions during this interval include ordering imaging, obtaining staging biopsies or sampling, documenting tumor board decisions, and scheduling neoadjuvant therapy or definitive surgery once staging is complete.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Standard submission when no modifier applies |