Summary & Overview
HCPCS G9502: Documentation of Medical Reason for Not Performing Foot Exam
HCPCS Level II code G9502 indicates documentation that a foot exam was not performed because the patient had bilateral or both-side lower-extremity amputations (above or below the knee) prior to or during the measurement period. This code matters nationally because it ensures appropriate capture of clinically justified exclusions from preventive foot exams—most commonly relevant in diabetes care quality measurement and reporting frameworks. Proper use of the code helps maintain the integrity of quality metrics and claims records when a standard exam is not clinically feasible.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical context for using G9502, how it relates to preventive diabetic foot exam workflows, and which sites of service typically document this exclusion. The publication also outlines benchmarking and reporting implications where available and highlights where input data was not provided. The content is intended for clinicians, billing staff, compliance officers, and policy analysts seeking clear guidance on the code’s purpose and application in national reporting and claims documentation.
Billing Code Overview
HCPCS Level II code G9502 documents the medical reason for not performing a foot exam when a patient has undergone either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period. This code captures clinical documentation that the foot exam was not applicable due to lower-extremity amputations.
Service type: Documentation of medically excluded preventive/diabetes foot exam
Typical site of service: Outpatient clinic, primary care setting, endocrinology or diabetes clinic, and other ambulatory care settings where preventive diabetic foot exams are normally performed.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult with bilateral lower-limb amputation above or below the knee who presents for a routine diabetic or vascular follow-up visit during the quality measurement period. Because the patient lacks both feet, a clinician documents the medical reason that a foot exam was not performed. The workflow: during the outpatient visit (primary care, endocrinology, or vascular surgery clinic), the clinician reviews the problem list, confirms bilateral lower-extremity amputation in the record and on exam, documents the amputation level and timing (prior to or during the measurement period), and records a statement that foot exam was not performed for medical reasons. The clinician signs the note; the coder links the encounter to billing code G9502 to reflect documentation of medical reason for not performing the foot exam. Typical sites of service include outpatient primary care clinics, endocrinology clinics, vascular surgery clinics, wound care centers, and rehabilitation or prosthetics clinics. The typical patient scenario includes a history of diabetes mellitus with peripheral arterial disease leading to bilateral below-knee or above-knee amputations performed prior to the measurement period, with ongoing chronic care visits where foot examination cannot be performed due to absence of both feet.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services |