Summary & Overview
HCPCS G9367: At Least Two Orders for High-Risk Medications from Same Drug Class
HCPCS Level II code G9367 identifies encounters in which a patient has at least two orders for high-risk medications from the same drug class. The code is intended to highlight potential safety issues related to duplicate or overlapping high-risk therapy and to support medication management, reconciliation, and review workflows across care settings. Nationally, tracking such events is relevant to patient safety initiatives, quality measurement, and utilization review.
Key payers covered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical intent, typical service settings (pharmacy review, ambulatory clinics, inpatient medication management), and how payers commonly treat documentation and billing for medication-safety encounters. The publication includes practical benchmarks and reporting considerations where available, summarizes relevant policy and billing elements, and provides clinical context around high-risk medication classes to clarify when G9367 may apply.
Data not available in the input for specific modifiers, associated taxonomies, ICD-10 diagnoses, related codes, and service-line particulars.
Billing Code Overview
HCPCS Level II code G9367 denotes at least two orders for high-risk medications from the same drug class. This billing entry captures instances where a patient has received multiple distinct orders for medications considered high-risk and belonging to the same therapeutic or safety-sensitive class.
Service type: Medication management / pharmacy review. Typical site of service: inpatient and outpatient pharmacy settings, ambulatory clinics, and care coordination environments where medication orders are reviewed or reconciled.
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Clinical & Coding Specifications
Clinical Context
A 72-year-old female resident of a skilled nursing facility is admitted to a geriatric medicine clinic for medication reconciliation after multiple recent hospital transfers. Her medication list shows two active orders for high-risk benzodiazepines from the same drug class — lorazepam and diazepam — both prescribed by different providers. The clinic pharmacist documents the duplicate high-risk class orders during a comprehensive medication review and generates a report for the primary care provider and the facility medical director. The clinical workflow includes: medication list reconciliation, verification of active orders in the electronic health record, cross-check against recent progress notes and transfer summaries, pharmacist clinical note generation, communication to prescribing clinicians, and updating the medication administration record in the long-term care facility. The billable event corresponds to identifying at least two orders for high-risk medications from the same drug class, triggering care coordination and potential deprescribing actions documented in the chart. Typical site of service is an outpatient clinic, long-term care facility, or institutional setting where medication management reviews occur. Common payors for related billing are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when documentation supports substantially greater work or complexity in the medication review due to complicating comorbidities or extensive reconciliation across multiple facilities. |
23 | Unusual anesthesia | Not commonly applicable; include only if anesthesia services were unexpectedly required during a related procedure. |
52 | Reduced services | Use when the medication review or reconciliation service was partially completed or truncated. |
53 | Discontinued procedure | Use if the medication reconciliation process was started but discontinued due to patient transfer or clinical instability. |
54 | Surgical care only | Not typically applicable; rarely used in this context unless billing-related surgical care is split. |
55 | Postoperative management only | Not typically applicable; used only when postoperative management is separately billed and relevant. |
56 | Preoperative management only | Not typically applicable; use only when preoperative medication reconciliation is billed separately. |
62 | Two surgeons | Use only if two clinicians with distinct taxonomy share responsibility for complex medication management decisions during a procedural encounter. |
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for covered surgical procedures | Use when an APP provides the billed medication reconciliation service under applicable rules. |
CO | Left or right modifier (institutional use in some systems) | Use per payer rules when designating laterality for site-specific services if required by local billing guidance. |
CQ | Service furnished by a physical therapist in part B therapy cap exemption | Generally not applicable; include only if a therapy-related medication review intersects with physical therapy services. |
FX | Indicates fractured service line (facility billing) | Use when facility billing requires a specific facility modifier for reporting an interrupted service. |
FY | Indicates accelerated payment request | Use only when an accelerated payment is requested per payer policies. |
QK | Medical direction of two, three, or four concurrent anesthesia procedures | Not applicable in routine medication reconciliation encounters. |
QX | CRNA service with medical direction by a physician | Not applicable in this context. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
2084P0800X | Geriatric Medicine | Frequent provider for medication reviews in elderly patients and long-term care. |
207Q00000X | Family Medicine | Commonly manages chronic medications and coordinates reconciliation. |
207R00000X | Internal Medicine | Primary providers conducting comprehensive medication management and reconciliation. |
3336C0002X | Clinical Pharmacist | Pharmacists perform medication therapy management and document high-risk medication duplication. |
363L00000X | Long Term Care Facility | Facility-based clinicians or medical directors overseeing medication administration records. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
F01.50 | Vascular dementia without behavioral disturbance | Dementia patients are at higher risk for inappropriate prescribing and duplicate high-risk sedative orders. |
F03.90 | Unspecified dementia, unspecified | Cognitive impairment increases risk of medication harm and the need for medication reconciliation. |
I10 | Essential (primary) hypertension | Common comorbidity in older adults undergoing medication reviews; relevant to overall med management. |
E11.9 | Type 2 diabetes mellitus without complications | Chronic disease typical in patients receiving complex medication regimens. |
G47.00 | Insomnia, unspecified | May prompt benzodiazepine or sedative prescriptions, increasing likelihood of duplicate orders. |
R41.82 | Altered mental status, unspecified | May trigger urgent medication review when multiple sedatives are prescribed. |
Z91.120 | Patient's intentional underdosing of medication regimen | Medication adherence issues can complicate reconciliation and duplicate-order assessments. |
Z79.899 | Other long term (current) drug therapy | Denotes chronic medication use and the need for periodic reconciliation. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
99213 | Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes | Often billed for the clinic visit during which medication reconciliation and identification of duplicate high-risk class orders occur. |
99495 | Transitional care management services with moderate complexity medical decision making; within 14 days of discharge | May be billed when medication reconciliation for high-risk medications is performed as part of transitional care after hospital discharge. |
99406 | Smoking and tobacco use cessation counseling, intermediate, 3-10 minutes | Example of a brief counseling CPT that may be billed alongside medication reconciliation when counseling on medication risks is provided; used when relevant counseling occurs. |
99605 | Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, initial 15 minutes | Used when a pharmacist documents a face-to-face medication therapy management session identifying duplicate high-risk class medications. |
96160 | Administration of patient-focused health risk assessment instrument | May be used when structured risk assessments for medication-related harm are performed during the medication review. |