Summary & Overview

HCPCS G9509: Depression Remission at 12 Months

HCPCS Level II code G9509 denotes documentation that an adult patient (18 years or older) with major depression or dysthymia achieved remission at twelve months, defined by a PHQ-9 or PHQ-9M score under 5 within a +/-60 day window. This measure captures long-term clinical response and is important for quality measurement, population health management, and behavioral health performance reporting nationwide. Payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will learn what the code represents clinically, where the service is typically delivered, and why twelve-month remission is a notable quality indicator for depressive disorders. The publication provides context on benchmarking and reporting relevance for payers and providers, highlights implications for outpatient behavioral health and primary care workflows, and outlines what documentation and assessment timing the code reflects. Data not available in the input for associated taxonomies, ICD-10 diagnoses, related codes, and service line is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9509HCPCS Level IIdepression remissionPHQ-9behavioral healthquality measureoutcome assessmentoutpatient care

Billing Code Overview

HCPCS Level II code G9509 applies to adult patients aged 18 years and older with major depression or dysthymia who reached remission at twelve months, as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5. The measure documents sustained remission of depressive symptoms at the twelve-month follow-up mark.

Service type: Behavioral health follow-up / outcome assessment

Typical site of service: Outpatient behavioral health clinics, primary care offices, and integrated care settings where depression monitoring and follow-up assessments are performed

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 45-year-old adult with a history of major depressive disorder (recurrent) began a structured treatment program including pharmacotherapy and psychotherapy. The patient had baseline symptom measurement with a PHQ-9 at intake, regular follow-up visits, and documented symptom monitoring at 3, 6, and 12 months. At the twelve-month visit (within +/- 60 days), a PHQ-9M/PHQ-9 self-report was completed and scored at 3, demonstrating remission (score < 5). The clinical workflow includes: initial psychiatric or primary care evaluation, establishment of a treatment plan, periodic outcome measurement with the PHQ-9 instrument, documentation of remission at twelve months, and billing of the HCPCS Level II code G9509 by the treating clinician or practice for reporting performance/outcome of depression remission at 12 months in adults.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work or resources for documenting or coordinating care for depression remission are substantially greater than typical.
`23`	Unusual anesthesia	Not typically applicable; included only if unusual anesthesia-related services are provided in conjunction with a visit (rare).
`52`	Reduced services	Use when the full set of service elements for outcome measurement was partially completed.
`53`	Discontinued procedure	Use if the visit or measurement was begun but discontinued for clinical reasons before completion.
`54`	Surgical care only	Not generally applicable; reserved for postoperative surgical team billing when psychiatric measurement is not part of that claim.
`55`	Postoperative management only	Not generally applicable; use when only postoperative management is billed separate from the measurement visit.
`56`	Part-time or intermittent care	Use if the reporting clinician provided only intermittent care in a team-based model and needs to indicate reduced participation.
`62`	Two surgeons	Rare; use only if two separate practitioners of record share responsibility for the same procedural service in a way that affects billing.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Generally not applicable to this measure but available for relevant clinician roles.
`CO`	Services related to a worker’s compensation case	Use when the patient’s treatment and outcome measurement are billed under worker’s compensation coverage.
`CQ`	Service furnished by a RN, LPN, or LVN in an outpatient setting	Use when a licensed nurse completes the PHQ-9M administration under supervision and payer allows reporting.
`FX`	Left hemisphere (example from anatomic modifiers set)	Not applicable clinically to this service; included from the provided list but rarely used.
`FY`	Right hemisphere (example from anatomic modifiers set)	Not applicable clinically to this service; rarely used.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals	Not applicable to depression outcome reporting.
`QX`	CRNA service with medical direction	Not applicable to this service.

Taxonomy Code	Specialty	Notes
`Data not available in the input.`	Data not available in the input.	Data not available in the input.
`Data not available in the input.`	Data not available in the input.	Data not available in the input.
`Data not available in the input.`	Data not available in the input.	Data not available in the input.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F32.9`	Major depressive disorder, single episode, unspecified	Common diagnosis for adults treated for a depressive episode and monitored for remission at 12 months.
`F33.1`	Major depressive disorder, recurrent, moderate	Frequently encountered in patients undergoing ongoing treatment where 12-month remission is assessed.
`F33.2`	Major depressive disorder, recurrent severe without psychotic features	Relevant for long-term outcome tracking where remission after 12 months is a target.
`F34.1`	Dysthymia (persistent depressive disorder)	Chronic depressive disorder where symptom remission at 12 months is an important outcome metric.
`Z13.89`	Encounter for screening for other disorder	May be used when screening and outcome measurement instruments such as PHQ-9 are administered in preventive contexts.
`Z71.9`	Counseling, unspecified	May be used adjunctively to indicate counseling services provided during management and follow-up of depression.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99420`	Administration and interpretation of health risk assessment instrument (e.g., PHQ-9 may be part of risk assessment)	May be used when a structured assessment instrument is administered and interpreted as part of a primary care visit documenting remission.
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory), with scoring and documentation, per standardized instrument	Commonly used for brief PHQ-9 administration and scoring in outpatient settings alongside reporting of remission.
`90833`	Psychotherapy, 30 minutes with evaluation and management for crisis or complex outpatient psychotherapy (add-on)	May be billed when psychotherapy is provided in the same encounter as the outcome assessment and E/M services.
`99406`	Smoking and tobacco cessation counseling, intermediate, 3-10 minutes	Example of a behavioral counseling CPT that can co-occur with depression management visits; included as a commonly performed adjacent service.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity	Often billed for the outpatient follow-up visit during which the PHQ-9M is completed and remission is documented.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, high complexity	Used when the follow-up visit documenting remission requires medically significant history, exam, and medical decision making of moderate to high complexity.