Summary & Overview
HCPCS G9394: Bipolar or Personality Disorder, Death, Nursing Home, Hospice
HCPCS Level II code G9394 identifies patients who should be considered outside standard performance measures because they had a diagnosis of bipolar disorder or a personality disorder, experienced death, were permanent nursing home residents, or were receiving hospice or palliative care during the measurement or assessment period. Nationally, such exclusion or exception codes are important for accurate quality measurement and risk adjustment, ensuring that reported performance reflects appropriate patient populations. Key payers included in this review are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will learn what G9394 represents clinically and operationally, which payers recognize the code, and how it is used in quality reporting workflows. The publication provides benchmarks and policy context where available, explains typical service settings tied to the code, and outlines implications for measure denominators and reporting completeness. Data not available in the input will be identified as such in relevant sections.
Billing Code Overview
HCPCS Level II code G9394 designates a patient who, at any time during the measurement or assessment period, had a diagnosis of bipolar disorder or personality disorder, experienced death, was a permanent nursing home resident, or was receiving hospice or palliative care. This code captures patient status or circumstances that can affect clinical measurement and quality reporting.
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Service type: Performance exclusion/denominator exception reporting related to behavioral health and quality measurement.
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Typical site of service: Long-term care facilities (permanent nursing homes), hospice settings, palliative care settings, and other settings where patients with serious mental health diagnoses or end-of-life care are managed.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult patient enrolled in an outpatient behavioral health program who meets exclusion criteria for certain quality measures due to one of the conditions in billing code G9394. For example, a 78-year-old permanent nursing home resident with advanced dementia who is receiving palliative care is admitted to the facility and has a documented history of bipolar disorder. During the measurement period the resident transitions to hospice services; the facility clinician documents hospice enrollment and the resident’s psychiatric diagnoses in the medical record. The clinical workflow includes chart review by a quality analyst who flags the record for exclusion from depression or behavioral-health follow-up measures, capture of the G9394 code on the claim or encounter form, inclusion of supporting documentation in the resident’s chart (hospice orders, nursing home residency status, or psychiatric diagnosis list), and notification to the third-party payer if required by the plan’s reporting process. Typical clinicians involved include psychiatrists, geriatricians, nurse practitioners, hospice physicians, and nursing home medical directors. Typical administrative steps include confirming the patient meets one of the listed conditions (bipolar disorder or personality disorder, death during period, permanent nursing home resident, or receiving hospice/palliative care), attaching supporting documentation, and appending the appropriate modifier(s) from the allowed set when relevant to billing or payment adjustments.
Coding Specifications
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