Summary & Overview
HCPCS G9370: Antipsychotic Medication Nonadherence
HCPCS Level II code G9370 denotes patients who did not fill at least two prescriptions for any antipsychotic medication or who did not achieve a proportion of days covered (PDC) of 0.8 or greater. The code is used to flag antipsychotic medication nonadherence, a clinically significant issue linked to relapse, hospitalization, and increased healthcare utilization across the country. National attention to antipsychotic adherence affects quality measurement, care management, and population health programs.
This analysis covers major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what the code represents, typical settings where it is captured, and the policy and clinical context for its use. The publication summarizes benchmarks where available, notes areas where input data are missing, and outlines implications for payer reporting and behavioral health quality monitoring. The content is intended for health plan analysts, revenue cycle managers, behavioral health clinicians, and policy stakeholders interested in medication adherence metrics and coding for outpatient and care management workflows.
Billing Code Overview
HCPCS Level II code G9370 identifies an individual who did not fill at least two prescriptions for any antipsychotic medication or did not have a proportion of days covered (PDC) of 0.8 or greater. This code captures medication nonadherence for antipsychotic therapy.
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Service type: Medication adherence assessment for antipsychotic therapy
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Typical site of service: Behavioral health clinics, outpatient mental health practices, primary care clinics, and care management programs where medication fills and adherence are reviewed
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 42-year-old patient with schizophrenia is seen in an outpatient psychiatric clinic for medication management. The patient was initiated on an oral antipsychotic three months ago but has missed multiple refills and presents for follow-up. Pharmacy claims and the electronic medication fill history indicate the patient did not fill at least two prescriptions and the proportion of days covered (PDC) is below 0.8. The clinician reviews adherence, documents barriers (cost, side effects, or access), and records interventions such as counseling, care coordination with the pharmacy, prescription synchronization, or consideration of a long‑acting injectable. The visit includes review of current medications, assessment of psychiatric stability, and a care plan focused on improving adherence. Typical workflow: verification of pharmacy fill history, calculation of PDC from medication fill dates, clinician documentation of nonadherence and reasons, and coding the nonadherence measure for quality reporting or care management billing using G9370.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service | Use when an E/M visit for assessment of medication adherence is distinct from other services provided the same day. |
| | Distinct procedural service | Use when a separate, unrelated service is performed the same day that should be reported apart from adherence counseling.