Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g9368-high-risk-medication-orders-not-ordered
    Ask Trek AI about this page

    HCPCS G9368: High-Risk Medication Orders Not Ordered

    HCPCS Level II code G9368 documents when at least two orders for high-risk medications from the same drug class were not ordered, representing a medication safety/clinical decision event; the service is categorized as a medication management/clinical documentation action typically occurring in inpatient or outpatient clinical settings where prescribing and order reconciliation occur.

    For related coverage guidance, see recent payer policy updates: Esophagogastroduodenoscopy (EGD) Coverage Policy, Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD), Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing.

    Customize your policy alerts

    Sign up for hcpcs G9368 policy alerts

    Get alerted when payer policies referencing G9368 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Table of contents

    Progress1 / 7

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    Clinical & Coding Specifications

    Clinical Context

    A typical patient is an adult inpatient on a medical ward or in a skilled nursing facility who has multiple comorbidities such as chronic pain, anxiety disorders, or insomnia. During medication reconciliation, the treating clinician identifies two or more orders for medications from the same high‑risk drug class (for example, two benzodiazepines or two opioids) that were placed concurrently or within the same ordering episode. The pharmacist or prescribing clinician applies the safety rule represented by G9368 to document that at least two orders for high‑risk medications from the same drug class were not ordered to avoid duplication and mitigate risk of adverse events (oversedation, respiratory depression, drug interactions). Typical workflow: medication reconciliation or computerized provider order entry (CPOE) review → clinical pharmacist or prescriber identifies potential duplicate high‑risk class orders → clinician documents the discontinuation or non‑ordering action in the medical record with supporting rationale and timing → coder assigns G9368 to indicate the safety action. Typical site of service is inpatient acute care units, observation units, emergency departments, or skilled nursing facilities where active medication management and reconciliation occur.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99223Initial hospital care, typically 70 minutes or moreAdmission evaluation by the attending physician during which comprehensive medication reconciliation and non‑ordering decisions for duplicate high‑risk medications are documented.
    99238Hospital discharge day management; 30 minutesDischarge medication reconciliation where duplicate high‑risk orders are reviewed and not continued; documentation supports safe transitions of care.
    99406Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutesExample of a counseling service that may accompany medication management but not directly related; included as a common adjunct in inpatient behavioral health settings (if applicable).
    99605Medication therapy management service(s) provided by a pharmacist, face-to-face, initial 15 minutesPharmacist‑led medication therapy management and reconciliation that identifies and documents the non‑ordering of duplicate high‑risk medications.
    99495Transitional care management, moderate complexity (within 14 days)Post‑discharge contact that includes medication reconciliation and confirmation that duplicate high‑risk drugs were not continued.

    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
    207Q00000XFamily Medicine PhysicianFamily Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadt…
    208D00000XGeneral Practice PhysicianA physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    207L00000XAnesthesiology PhysicianAn anesthesiologist is trained to provide pain relief and maintenance, or restoration, of a stable condition during and immediately following an opera…
    207R00000XInternal Medicine PhysicianA physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
    208100000XPhysical Medicine & Rehabilitation PhysicianPhysical medicine and rehabilitation, also referred to as rehabilitation medicine, is the medical specialty concerned with diagnosing, evaluating, and…
    2279C0205XCritical Care Registered Respiratory TherapistRespiratory emergencies are commonplace in the treatment of critical care patients. Included in the assessment measurements conducted by the respirat…
    207ZC0006XClinical Pathology PhysicianA pathologist deals with the causes and nature of disease and contributes to diagnosis, prognosis and treatment through knowledge gained by the labora…

    Related ICD-10-CM Codes

    25 rows

    ICD-10-CM CodeDescription
    E03.9Hypothyroidism, unspecified
    E11.9Type 2 diabetes mellitus without complications
    E78.5Hyperlipidemia, unspecified
    E86.0Dehydration
    F06.8Other specified mental disorders due to known physiological condition
    F10.20Alcohol dependence, uncomplicated
    F11.20Opioid dependence, uncomplicated
    F17.210Nicotine dependence, cigarettes, uncomplicated
    F32.9Major depressive disorder, single episode, unspecified
    F33.1Major depressive disorder, recurrent, moderate

    Showing 1–10 of 25

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 3

    7 rows

    PolicyPayerEffective Date
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01
    Celiac Disease TestingOscar Health2026-10-01

    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

    • More pages

    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.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.