Summary & Overview
HCPCS G9526: Patient Not Referred to Hospice Care
HCPCS Level II code G9526 documents that a patient was not referred to hospice care and that no reason was provided. This administrative clinical code captures a discrete decision point in patient care coordination and end-of-life planning. Nationally, documenting hospice referral status matters for quality measurement, care transitions, and administrative reporting across inpatient and outpatient settings.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what G9526 represents, how and where it is used, and the implications for clinical documentation and billing workflows. The publication also outlines common modifiers and administrative considerations, benchmarks where available, and the clinical context for hospice referral documentation.
This summary is written for a national audience and focuses on the code’s purpose, payer coverage, and the types of operational and quality-reporting topics readers can expect to explore.
Billing Code Overview
HCPCS Level II code G9526 indicates that the patient was not referred to hospice care, reason not given. This code documents the absence of a hospice referral when a referral decision point existed.
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Service type: Documentation of hospice referral decision
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Typical site of service: Inpatient or outpatient clinical settings where end-of-life care decisions are made, including hospitals, physician offices, and outpatient clinics.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult with advanced, progressive illness (for example, metastatic cancer, end-stage heart failure, or advanced chronic obstructive pulmonary disease) who meets clinical criteria for hospice care but was not referred to hospice; the billing code G9526 documents that hospice referral was not made and no reason was given. In practice this occurs during an outpatient or inpatient evaluation when the treating clinician assesses prognosis and goals of care, determines hospice may be appropriate, but no referral is entered into the medical record and no reason is documented. The clinical workflow: the clinician completes the clinical assessment, documents the plan of care and decision-making, and if hospice referral is not placed, the clinician or staff assigns G9526 to indicate absence of a hospice referral without a stated reason. Typical sites of service include acute inpatient wards, hospital observation, outpatient specialty clinics (oncology, cardiology, pulmonology), palliative care consult services, and skilled nursing facilities. Common patient presentation: progressive functional decline, repeated hospitalizations for complications of advanced disease, and discussion of goals of care where hospice is considered but not initiated or documented.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |