Summary & Overview
HCPCS G9116: Ovarian Cancer Disease Status — Progression/Recurrence/Platinum Resistance
HCPCS Level II code G9116 captures an oncology disease-status assessment specific to epithelial ovarian cancer, indicating documented evidence of disease progression, recurrence, or platinum resistance and designated for use in a Medicare-approved demonstration project. This code matters nationally because it targets a high-impact clinical scenario — recurrent or treatment-resistant ovarian cancer — and supports standardized reporting within demonstration initiatives that can inform policy and care pathways.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical scope and intended service settings, plus an overview of the policy context for Medicare demonstration use. The publication also summarizes benchmarking considerations and coding clarity that payers and providers may reference when aligning documentation and claims for disease-status evaluations in oncology.
The report provides: (1) clinical context for when G9116 applies, (2) expected service locations and workflows, and (3) implications for documentation and program reporting within Medicare demonstration projects. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code G9116 denotes a service related to oncology disease status assessment for ovarian cancer, limited to epithelial cancer, documenting evidence of disease progression, recurrence, and/or platinum resistance. The code is specified for use in a Medicare-approved demonstration project.
Service Type: Disease status assessment / oncology follow-up
Typical Site of Service: Oncology clinic or other ambulatory cancer care setting where disease status evaluations are conducted
Clinical & Coding Specifications
Clinical Context
A typical patient is a postmenopausal woman with known epithelial ovarian cancer who presents to a gynecologic oncology clinic or infusion center with signs or imaging evidence suggesting disease progression, recurrence, or development of platinum resistance. The clinical workflow begins with a focused oncology visit where the treating gynecologic oncologist or medical oncologist documents histologic subtype (epithelial ovarian cancer), prior platinum-based chemotherapy history, and evidence supporting progression or recurrence (serial CA-125 rise, cross-sectional imaging such as CT or PET/CT, or clinical exam). The clinician determines eligibility for participation in a Medicare-approved demonstration project and documents objective evidence of progression, recurrence, or platinum resistance in the medical record. Relevant team members include the gynecologic oncologist, medical oncologist, oncology nurse navigator, and medical records coder. Typical sites of service are outpatient oncology clinics, hospital-based outpatient departments, and cancer center clinics. The encounter may coincide with treatment planning, initiation of second-line systemic therapy, enrollment in a clinical demonstration program, or documentation required for coverage determination related to disease status coding G9116.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Standard reporting when no special circumstances apply |