Summary & Overview
HCPCS G9107: Pancreatic Adenocarcinoma Disease Status, Advanced
HCPCS Level II code G9107 captures documented disease status for patients with pancreatic adenocarcinoma who are unresectable at diagnosis, metastatic (m1) at diagnosis, locally recurrent, or progressive, and is intended for use within a Medicare-approved demonstration project. Nationally, this code provides a standardized way to record advanced pancreatic cancer status in project settings, supporting clinical tracking and program reporting.
Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical scope, typical sites of service, and the demonstration-project context that limits its use. The publication outlines what stakeholders can expect regarding documentation needs, common modifiers associated with the code (listed separately), and where this code fits within oncology service lines.
This summary also highlights the implications for national reporting and program evaluation, clarifies the clinical situations covered by the code, and points to where additional coding and billing details would be located. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code G9107 denotes oncology disease status specific to pancreatic adenocarcinoma that is unresectable at diagnosis, m1 (metastatic) at diagnosis, metastatic, locally recurrent, or progressive and is designated for use in a Medicare-approved demonstration project.
Service Type: Oncology — disease status assessment and reporting in advanced pancreatic adenocarcinoma
Typical Site of Service: Hospital outpatient oncology clinics, cancer centers, and specialty oncology practices participating in demonstration projects
This code is intended to capture the documented disease status for patients with pancreatic adenocarcinoma who meet the described clinical criteria within the parameters of the demonstration project.
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient with newly diagnosed pancreatic adenocarcinoma presents to a tertiary cancer center for enrollment in a Medicare-approved demonstration project tracking disease status and outcomes. The tumor was judged unresectable at diagnosis based on vascular encasement on cross-sectional imaging and staging revealed distant metastases (M1). The multidisciplinary workflow includes oncology intake, review of imaging and pathology, documentation of disease extent (primary tumor, regional nodes, metastatic sites), performance status, prior treatments, and planned systemic therapy or palliative interventions. Clinical activities captured under this billing descriptor include disease status assessment visits, radiology review, tumor board documentation, and care-plan updates specific to unresectable or metastatic pancreatic adenocarcinoma during the demonstration project period. Typical sites of service are outpatient oncology clinics, hospital-based cancer centers, and integrated ambulatory infusion centers participating in the demonstration project. Common accompanying services include diagnostic CT/MRI, pathology review, systemic chemotherapy administration, palliative consultations, and periodic restaging assessments.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — standard service | Use when no qualifying modifier applies to the billed service |
22 | Increased procedural services | Use when work required is substantially greater than typically required (document justification) |
23 | Unusual anesthesia | Use when a procedure normally done without general anesthesia requires it due to patient condition |
52 | Reduced services | Use when service provided is partially reduced or omitted at physician discretion |
53 | Discontinued procedure | Use when a procedure is started but discontinued due to extenuating circumstances |
54 | Surgical care only | Use when billing only the surgical component; relevant if surgical attempt documented separately |
55 | Postoperative management only | Use when billing only global postoperative care, not intraoperative services |
56 | Preoperative management only | Use when billing only preoperative evaluation without subsequent procedure |
62 | Two surgeons | Use when two surgeons of different specialties perform distinct parts of a complex operation |
AS | Physician assistant, nurse practitioner, or clinical nurse specialist service | Use when service is performed by an advanced practice clinician under appropriate supervision |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207RC0000X | Medical Oncology | Primary specialty managing systemic therapy and disease-status assessment |
208800000X | Radiation Oncology | Involved when palliative radiotherapy is considered for local control or symptom relief |
207L00000X | Hematology/Oncology | Combined specialty often responsible for systemic treatment planning and staging documentation |
364S00000X | General Surgery | Surgical oncology evaluation for resectability assessment or biopsy procedures |
363LF0000X | Nurse Practitioner | Advanced practice clinicians who document disease status and coordinate outpatient care |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C25.9 | Malignant neoplasm of pancreas, unspecified | Primary diagnosis for pancreatic adenocarcinoma when site within pancreas is not further specified |
C25.1 | Malignant neoplasm of body of pancreas | Site-specific code for tumors located in the pancreatic body when relevant to staging and resectability |
C25.2 | Malignant neoplasm of tail of pancreas | Site-specific code relevant to operative planning and symptomatology |
C78.7 | Secondary malignant neoplasm of liver and intrahepatic bile duct | Common metastatic site for pancreatic adenocarcinoma (M1 disease) and influences prognosis and therapy |
C78.4 | Secondary malignant neoplasm of respiratory and digestive systems, pleura | Represents thoracic metastatic spread which may be seen in advanced disease |
Z85.07 | Personal history of malignant neoplasm of pancreas | Used when documenting prior history in longitudinal care and surveillance contexts |
R17 | Unspecified jaundice | Common presenting symptom in pancreatic cancer due to biliary obstruction and relevant to staging and palliation |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
36415 | Collection of venous blood by venipuncture | Often performed for baseline labs, tumor markers (e.g., CA 19-9) prior to systemic therapy |
74177 | CT abdomen and pelvis with contrast, diagnostic | Used for initial staging and periodic restaging to document unresectable or metastatic disease |
43246 | Upper GI endoscopy with biopsy, single or multiple | May be performed to obtain tissue diagnosis if pancreatic mass accessible via endoscopy or EUS-guided biopsy |
96413 | Chemotherapy administration, infusion technique; up to 1 hour, single or initial drug | Commonly billed when systemic chemotherapy is administered as part of treatment for unresectable/metastatic pancreatic adenocarcinoma |
G6015 | Oncology care and coordination service (example care management) | Used in care coordination activities during demonstration projects to document disease status and plan of care |