Summary & Overview
HCPCS G9226: Comprehensive Foot Examination, Sensory and Vascular Assessment
HCPCS Level II code G9226 denotes a comprehensive foot examination that combines visual inspection, a 10-g monofilament sensory test, one additional sensory or reflex assessment (vibration with a 128-Hz tuning fork, pinprick, ankle reflexes, or vibration perception threshold), and a pulse exam. The code is intended to capture a complete foot assessment often used to screen for peripheral neuropathy and vascular compromise, which are critical in the care of patients with diabetes and other conditions that increase risk for foot complications. Nationally, standardized use of this code supports consistent documentation of preventive foot care and risk stratification for complications.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for the service, expected sites of service, and the common modifiers associated with billing for this code. The publication covers benchmarking and coverage considerations typically relevant to national payers, summarizes how the examination components map to clinical practice, and highlights where policy updates or payer-specific guidance may affect reporting and reimbursement. Data not available in the input is noted where applicable, and the content focuses on nationally applicable information rather than state-specific rules.
Billing Code Overview
HCPCS Level II code G9226 describes a foot examination performed that includes visual inspection, a sensory exam using a 10-g monofilament, and testing of any one of the following: vibration with a 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold, plus a pulse exam. The code is reported when all three components described are completed.
Service Type: Comprehensive foot screening/examination
Typical Site of Service: Outpatient clinic or office-based setting, including primary care, podiatry, endocrinology, and wound care clinics where focused foot exams for neuropathy and vascular assessment are performed.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with diabetes mellitus who presents for a routine preventive visit or diabetes foot surveillance. The clinician (primary care physician, endocrinologist, podiatrist, or nurse practitioner) performs a focused foot examination to assess risk for neuropathy and peripheral arterial disease. The workflow includes patient history (duration of diabetes, prior foot ulcers, neuropathic symptoms), removal of footwear and socks, inspection of both feet for skin integrity, calluses, deformities, ulcers, or infection; sensory testing using a 10-g monofilament at standardized plantar sites; testing one additional sensory or neurologic modality such as vibration with a 128-hz tuning fork, pinprick, ankle reflexes, or vibration perception threshold; and palpation of dorsalis pedis and posterior tibial pulses. Findings are documented in the medical record with risk stratification (no loss of protective sensation, loss of protective sensation, active ulceration) and follow-up recommendations. Typical sites of service include outpatient clinic, primary care office, endocrinology clinic, podiatry office, and ambulatory surgery center when performed as part of pre-procedure evaluation. The service is reported when all three required components (visual inspection, 10-g monofilament sensory exam plus one additional sensory/neurologic test, and pulse exam) are completed and documented during the encounter.
Coding Specifications
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