G9400 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS G9400: Documentation of Reasons for Not Discussing Treatment Options

HCPCS Level II code G9400 records documentation of medical or patient reasons for not discussing treatment options. Nationally, this code provides standardized capture of cases where clinicians do not engage in treatment-option discussions because the patient is not a candidate (due to advanced physical or mental health comorbidity, active substance use, or current antiviral therapy), has achieved sustained virologic response prior to the reporting period, or is unable or unwilling to participate. Consistent use of G9400 supports administrative clarity and quality measurement by distinguishing clinical or patient barriers from gaps in care delivery.

Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn what G9400 represents clinically and administratively, how it is typically applied across outpatient and ambulatory settings, and which payers commonly accept or adjudicate claims that document reasons for omission of treatment discussions. The publication also covers benchmark considerations, common billing modifiers (listed separately), and the clinical contexts in which documentation is most relevant. Data not available in the input where payer-specific rates, associated taxonomies, ICD-10 mappings, and related service-line details would normally appear.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9400HCPCS Level IItreatment-discussiondocumentationoutpatient-carequality-measurementantiviral-therapypatient-refusalclinical-exclusion

Billing Code Overview

HCPCS Level II code G9400 documents medical or patient reasons for not discussing treatment options. The code captures cases where discussion of treatment is not completed because the patient is not a candidate due to advanced physical or mental health comorbidity (including active substance use); the patient is currently receiving antiviral treatment; the patient had successful antiviral treatment (sustained virologic response) prior to the reporting period; other documented medical reasons; or because the patient is unable or unwilling to participate in the discussion or other patient reasons.

Service type: Documentation of reasons for omission of treatment discussion, typically used as a clinical administrative service to record rationale when treatment options are not addressed.

Typical site of service: Outpatient clinic, ambulatory care setting, or other outpatient medical encounters where treatment discussions and care planning would normally occur. Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient with chronic hepatitis C presents for routine hepatology follow-up. During the visit, the clinician determines that discussing antiviral treatment options is not appropriate for documented reasons: the patient currently has uncontrolled active substance use disorder and severe uncontrolled psychiatric comorbidity that make them not a candidate for treatment at this time. The clinician documents the medical reasons for not discussing treatment options in the medical record, including relevant assessments, prior treatment history, and care plan: referral to addiction and behavioral health services and a plan to reassess candidacy once comorbid conditions are stabilized. The workflow includes review of prior antiviral therapy, verification of current treatment status, assessment of capacity and contraindications, shared decision-making attempts as appropriate, explicit documentation of the medical or patient reasons for not engaging in treatment discussion, and coding the encounter with G9400 to indicate documentation of reasons for not discussing treatment options. Typical sites of service include outpatient hepatology or infectious disease clinics, primary care clinics managing hepatitis C, and specialty substance use or mental health clinics when co-management occurs. Typical patient scenarios include advanced comorbid medical or psychiatric illness, active substance use, current antiviral therapy, or a recent sustained virologic response documented prior to the reporting period.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS G9357: Postpartum Screenings, Evaluations, and Education

HCPCS-G0019-COMMUNITY-HEALTH-INTEGRATION-SDOH-CARE-COORDINATION

HCPCS G0019: Community Health Integration for Social Determinants of Health

HCPCS-G9728-PATIENT-REFUSED-TO-PARTICIPATE

HCPCS Level II G9728: Patient Refused to Participate

HCPCS-G0527-DEMENTIA-MANAGEMENT-ESTABLISHED-PATIENT-LOW-COMPLEXITY

HCPCS G0527: Management of Established Patient with Dementia, Low Complexity

HCPCS-G9329-DICOM-IMAGE-DATA-AVAILABLE-TO-EXTERNAL-FACILITIES

HCPCS G9329: DICOM Image Data Available to External Facilities

HCPCS-G9098-ESOPHAGEAL-CANCER-DISEASE-STATUS-METASTATIC

HCPCS G9098: Esophageal Cancer Disease Status Assessment

HCPCS-G9930-COMFORT-CARE-ONLY

HCPCS G9930: Patients Receiving Comfort Care Only

HCPCS-G8870-HEPATITIS-B-VACCINE-FIRST-COURSE-ANTI-TNF

HCPCS G8870: Hepatitis B Vaccine for Patients Starting Anti-TNF Therapy

HCPCS-G2003-MODERATE-POST-DISCHARGE-IN-HOME-VISIT-NEW-PATIENT

HCPCS G2003: Moderate Post-Discharge In-Home Visit for New Patients

HCPCS-G9148-NCQA-LEVEL-1-MEDICAL-HOME

HCPCS G9148: NCQA Level 1 Medical Home

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207RH0000X`	Gastroenterology	Hepatology and hepatitis C management are commonly performed by gastroenterologists.
`2080P0208X`	Infectious Disease	Infectious disease specialists manage hepatitis C antiviral candidacy and document reasons for not discussing treatment.
`208000000X`	Family Medicine	Primary care clinicians commonly document treatment discussions and reasons for deferral in outpatient settings.
`207L00000X`	Internal Medicine	General internists often manage chronic hepatitis C and associated comorbidities in clinic.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F11.20`	Opioid dependence, in remission, uncomplicated	Active or recent substance use disorders are common reasons to defer treatment discussion if uncontrolled.
`F10.20`	Alcohol dependence, uncomplicated	Active alcohol use disorders may impact candidacy for antiviral therapy and lead to documentation with `G9400`.
`F32.9`	Major depressive disorder, single episode, unspecified	Severe psychiatric comorbidity that interferes with treatment discussion or candidacy.
`Z79.899`	Other long term (current) drug therapy	Indicates ongoing treatments that may affect antiviral decisions or indicate current antiviral therapy.
`Z21`	Asymptomatic human immunodeficiency virus [HIV] infection status	Co-infections and comorbid conditions influence treatment planning and documentation of reasons for not discussing options.
`B18.2`	Chronic viral hepatitis C	Primary diagnosis for which treatment options would be discussed; documentation of reasons for not discussing is coded with `G9400`.
`Z98.890`	History of other specified postprocedural states	Prior successful antiviral treatment with sustained virologic response may be documented as a reason not to discuss further treatment.

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	Common E/M code for outpatient visits during which `G9400` documentation of reasons for not discussing treatment occurs.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used when the visit involves moderate to high complexity evaluation and documentation supporting `G9400` is present.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	May be performed during the same visit when active substance use is a reason for not discussing antiviral treatment.
`99407`	Smoking and tobacco use cessation counseling, intensive, greater than 10 minutes	Used when more intensive substance use counseling is provided and documented alongside reasons for deferring treatment discussion.
`99499`	Unlisted evaluation and management service	Used when no specific E/M or counseling code accurately reflects the complex documentation scenario accompanying `G9400`.

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