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    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g9198-cephalosporin-prophylaxis-order-not-documented
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    HCPCS G9198: Order for Cephalosporin Prophylaxis Not Documented

    HCPCS Level II code G9198 indicates that an order for a first- or second-generation cephalosporin for antimicrobial prophylaxis was not documented with a reason; this pertains to antimicrobial prophylaxis orders typically associated with perioperative or procedural prophylaxis and is usually encountered in inpatient or outpatient surgical settings where documentation of prophylactic antibiotic choice is required.

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient is an adult scheduled for a clean or clean-contaminated surgical procedure (for example: orthopedic joint arthroplasty, hysterectomy, colorectal resection, or certain vascular procedures) where perioperative antimicrobial prophylaxis with a first- or second-generation cephalosporin (such as cefazolin or cefuroxime) is standard of care. The patient arrives to the preoperative area for routine assessment. The surgical team documents planned antibiotic prophylaxis in the operative or anesthesia record and the perioperative nursing checklist; however, the specific order for the cephalosporin (agent, dose, route, and timing) is missing from the medication/order record. The absence of a documented order triggers a chart review query, and the coder flags the encounter for missing documentation. Typical workflow steps: preoperative evaluation by the surgeon or anesthesia provider, medication reconciliation and order entry by anesthesia or perioperative nursing, administration of the antibiotic in the operating room or pre-op holding area, and postoperative documentation in the operative note and medication administration record. The billing code G9198 is used to indicate that an order for a first- or second-generation cephalosporin for antimicrobial prophylaxis was not documented and no reason was given in the medical record.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99231Subsequent hospital care, per day, for the evaluation and management of a patient, established patientUsed for postoperative inpatient follow-up where documentation of antibiotic orders and rationale may be reviewed or queried.
    99238Hospital discharge day management; 30 minutes or lessDischarge documentation may need to include perioperative medications given, affecting resolution of missing order queries.
    96372Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscularIf a cephalosporin dose is administered subcutaneously or intramuscularly in the perioperative setting, this code documents the injection service.
    96365Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hourUsed when an intravenous antibiotic infusion is initiated perioperatively for prophylaxis and requires documentation.
    99291Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutesIn rare complex perioperative scenarios requiring critical care, documentation of prophylaxis orders may appear in critical care notes.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    207L00000XAnesthesiology PhysicianAn anesthesiologist is trained to provide pain relief and maintenance, or restoration, of a stable condition during and immediately following an opera…
    208D00000XGeneral Practice PhysicianA physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.
    207K00000XAllergy & Immunology PhysicianAn allergist-immunologist is trained in evaluation, physical and laboratory diagnosis, and management of disorders involving the immune system. Select…
    367A00000XAdvanced Practice MidwifeAdvanced practice midwifery encompasses the independent provision of care during pregnancy, childbirth, and the postpartum period; sexual and reproduc…
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    364SG0600XGerontology Clinical Nurse SpecialistPhysician Assistants & Advanced Practice Nursing Providers · Clinical Nurse Specialist
    363LP1700XPerinatal Nurse PractitionerPhysician Assistants & Advanced Practice Nursing Providers · Nurse Practitioner
    225XE0001XEnvironmental Modification Occupational TherapistOccupational therapy practitioners are experts at identifying the cause of difficulties in performance of activities of daily living and instrumental …

    Related ICD-10-CM Codes

    27 rows

    ICD-10-CM CodeDescription
    A41.9Sepsis, unspecified organism
    B95.61Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
    E11.9Type 2 diabetes mellitus without complications
    E78.5Hyperlipidemia, unspecified
    F41.9Anxiety disorder, unspecified
    G30.9Alzheimer's disease, unspecified
    I10Essential (primary) hypertension
    I20.9Angina pectoris, unspecified
    I63.9Cerebral infarction, unspecified
    J18.9Pneumonia, unspecified organism

    Showing 1–10 of 27

    Related Codes

    HCPCS-G9490-HOME-ASSESSMENT-NON-HOMEBOUND

    HCPCS G9490: Home Visit Patient Assessment for Non-Homebound Beneficiary

    HCPCS-G0008-INFLUENZA-VACCINE-ADMINISTRATION

    HCPCS G0008: Administration of Influenza Virus Vaccine

    HCPCS-G0009-PNEUMOCOCCAL-VACCINE-ADMINISTRATION

    HCPCS G0009: Administration of Pneumococcal Vaccine

    HCPCS-G0010-HEPATITIS-B-VACCINE-ADMINISTRATION

    HCPCS G0010: Administration of Hepatitis B Vaccine

    HCPCS-G0011-PREP-COUNSELING-HIV-RISK-REDUCTION-ADHERENCE

    HCPCS G0011: Individual PrEP Counseling, HIV Risk Assessment

    HCPCS-G0012-PRE-EXPOSURE-PROPHYLAXIS-INJECTION-HIV-PREVENTION

    HCPCS G0012: Injection of PrEP Drug for HIV Prevention

    HCPCS-G0013-PREP-INDIVIDUAL-COUNSELING-HIV-RISK-REDUCTION

    HCPCS G0013: Individual PrEP Counseling by Clinical Staff

    HCPCS-G0017-PSYCHOTHERAPY-CRISIS-FIRST-60-MINUTES-NON-OFFICE

    HCPCS G0017: Psychotherapy for Crisis, First 60 Minutes

    HCPCS-G0018-PSYCHOTHERAPY-CRISIS-ADDITIONAL-30-MINUTES-NON-OFFICE

    HCPCS G0018: Psychotherapy for Crisis, Additional 30 Minutes

    HCPCS-G0019-COMMUNITY-HEALTH-INTEGRATION-SDOH-CARE-COORDINATION

    HCPCS G0019: Community Health Integration, Person-Centered Assessment

    Showing 1–10 of 1996

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    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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