Summary & Overview

HCPCS G9507: Statin Medication or Valid Contraindication Documentation

HCPCS Level II code G9507 captures documentation that a patient is taking a statin medication or has a documented contraindication or exception to statin use. This code supports quality measurement and clinical record completeness for cardiovascular risk management, and it is used across outpatient and ambulatory settings where medication reconciliation and preventive care documentation occur. Nationally, accurate capture of statin use or valid exceptions is important for performance reporting, payer quality programs, and care coordination for patients at risk of atherosclerotic cardiovascular disease.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn what G9507 represents clinically, the typical service context where it is recorded, and the types of contraindications and exceptions that qualify for documentation. The publication also outlines the scope of information available for benchmarking and policy discussion. Data not available in the input prevents presentation of payer-specific rate benchmarks, associated taxonomies, and exact ICD-10 lists; those fields are noted as unavailable where applicable. This summary is intended as a national overview for health system coders, compliance staff, and quality analysts seeking concise guidance on the clinical meaning and documentation expectations associated with HCPCS Level II code G9507.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9507HCPCS Level IIstatin documentationmedication reconciliationquality measurementoutpatient servicescardiovascular prevention

Billing Code Overview

HCPCS Level II code G9507 documents that a patient is on a statin medication or that there is documentation of a valid contraindication or exception to statin therapy. Contraindications and exceptions that can be defined by diagnosis codes include pregnancy during the measurement period, active liver disease, rhabdomyolysis, end stage renal disease on dialysis, and heart failure. Provider-documented contraindications and exceptions include breastfeeding during the measurement period, woman of child-bearing age not actively taking birth control, allergy to statin, drug interaction (for example with certain HIV protease inhibitors, nefazodone, cyclosporine, gemfibrozil, and danazol), and intolerance with supporting documentation of a prior statin trial within the last five years or diagnoses for myostitis or toxic myopathy related to drugs.

Service type: Clinical documentation of medication status or documented contraindication/exception for statin therapy
Typical site of service: Ambulatory clinic or outpatient encounter where medication reconciliation and clinical documentation are completed

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with established atherosclerotic cardiovascular disease risk factors (for example, prior myocardial infarction, ischemic stroke, or diabetes with multiple risk factors) or with hyperlipidemia being managed in primary care or cardiology. During a routine chronic care visit or medication reconciliation encounter, the clinician documents that the patient is currently taking a statin or records a valid contraindication or exception to statin therapy. The workflow commonly includes medication list review, verification of prior statin trials or adverse effects, review of pregnancy/lactation status for women of childbearing potential, review of liver disease and renal failure history, and documentation of drug interactions or intolerance with supporting notes (for intolerance, documentation of a prior statin trial within the last 5 years or diagnostic codes for myositis/toxic myopathy). Typical visit locations include outpatient primary care clinics, cardiology clinics, preventive medicine visits, and chronic care management encounters. The service is administrative/clinical documentation rather than a procedure-based service and is used to satisfy quality measure reporting requirements related to statin therapy or documented contraindications/exceptions.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	When additional work beyond typical documentation is required (e.g., complex medication reconciliation for multiple interacting drugs).
`23`	Unusual anesthesia	Not typically applicable but may be appended if sedation/anesthesia unexpectedly used during a visit requiring documentation of statin status (rare).
`52`	Reduced services	When the encounter or documentation is partially performed or truncated.
`53`	Discontinued procedure	If the planned visit or documentation was started but discontinued before completion.
`54`	Surgical care only	Not typically applicable; included rarely if the statin documentation occurs in the context of separate surgical care.
`55`	Postoperative management only	Not typically applicable; used if documentation occurs solely during postoperative management visit.
`56`	Preoperative management only	When statin contraindication documentation is performed only as preoperative clearance.
`62`	Two surgeons	Not applicable to documentation code; used when two surgeons are required for a surgical procedure.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Not applicable; may be listed in systems requiring nonphysician practitioner identification.
`CO`	Routine maintenance services	Used by some payors to indicate contractually excluded services; applies to billing system flags where relevant.
`CQ`	Service furnished by a resident without an attending present	When a resident documents statin status independently per program rules.
`FX`	Single fracture fixation	Not applicable clinically; included in code set but rarely used for this service.
`FY`	Discontinued outpatient therapy	When planned outpatient therapy related to lipid management is discontinued and documentation reflects that.
`QK`	Medical direction of two, three, or four technicians/ASCs	Applicable in billing systems requiring delineation of supervisory arrangements for ancillary staff performing documentation tasks.
`QX`	Modifier for assistant-at-surgery when assistant is PA/NP/CNS	Not typically applicable; present for completeness when systems require assistant identification.

Taxonomy Code	Specialty	Notes
207Q00000X	Internal Medicine	Primary specialty managing chronic lipid therapy and statin documentation.
207RC0000X	Cardiology	Cardiology clinicians documenting secondary prevention statin therapy.
363L00000X	Nurse Practitioner	NP providers frequently document medication reconciliation and contraindications.
163W00000X	Physician Assistant	PAs commonly perform chronic care visits and document statin use or exceptions.
208D00000X	Family Medicine	Family medicine clinicians managing primary prevention and chronic statin therapy.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E78.5`	Hyperlipidemia, unspecified	Common diagnosis indicating need for statin therapy or documentation of exception.
`I25.10`	Atherosclerotic heart disease of native coronary artery without angina pectoris	Indicates secondary prevention where statin therapy is typically indicated or a documented exception is required.
`I63.9`	Cerebral infarction, unspecified	Ischemic stroke history prompts statin therapy for secondary prevention; documentation of use or contraindication is required.
`E11.9`	Type 2 diabetes mellitus without complications	Diabetes increases cardiovascular risk; statin therapy consideration and documentation commonly required.
`K71.6`	Toxic liver disease with hepatitis, unspecified	Active liver disease is a listed contraindication to statin therapy and must be documented if present.
`N18.6`	End stage renal disease	ESRD on dialysis is a listed exception/contraindication and should be documented when applicable.
`T46.6X5A`	Adverse effect of lipid-regulating agents, initial encounter	Used when a patient has a documented adverse reaction/intolerance to statins requiring exception documentation.
`O09.892`	Supervision of pregnancy with other specified maternal conditions, second trimester	Pregnancy during the measurement period is a contraindication to statin therapy and requires documentation when present.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99091`	Collection and interpretation of physiologic data digitally stored and/or transmitted by the patient to the physician or other qualified health care professional; requires a minimum of 30 minutes of time.	May be used in longitudinal remote monitoring programs where medication adherence and statin therapy are reviewed as part of remote physiologic data management.
`99490`	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.	Statin documentation and exceptions commonly occur as part of monthly chronic care management for patients with multiple chronic conditions.
`99495`	Transitional care management services with moderate complexity medical decision making and face-to-face visit within 14 days of discharge.	Statin therapy reconciliation and documentation often occur during transitional care visits after hospital discharge.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes.	Routine outpatient visit where statin use or contraindication documentation is commonly performed.
`99406`	Smoking and tobacco use cessation counseling, intermediate (greater than 3 minutes up to 10 minutes).	Often performed in the same visit as lipid management and statin counseling; documented separately when billed.