Summary & Overview
HCPCS G9618: Uterine Malignancy Screening or Endometrial Sampling
HCPCS Level II code G9618 denotes documentation that a patient was screened for uterine malignancy or underwent an ultrasound and/or endometrial sampling. Nationally, accurate use of this code supports clinical records that track cancer screening and diagnostic evaluation for uterine disease, informing quality measurement and administrative reporting. The code is relevant across outpatient gynecology practices, imaging centers, and ambulatory surgical settings where endometrial evaluation occurs.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical intent and service context, typical sites of service, and the payer landscape addressed for national applicability. The publication summarizes benchmarks where available, highlights recent policy considerations affecting use of HCPCS Level II codes in diagnostic documentation, and situates G9618 within clinical workflows for uterine malignancy evaluation.
This executive summary is aimed at clinicians, billing professionals, and policy analysts seeking a clear, national-level brief on the code’s purpose, payer relevance, and what content the full publication provides about coding practice and administrative implications.
Billing Code Overview
HCPCS Level II code G9618 documents screening for uterine malignancy or instances when a patient underwent an ultrasound and/or endometrial sampling of any kind. This code captures clinical documentation that providers use to indicate that evaluation for possible uterine cancer was performed or that diagnostic procedures of the endometrium (such as transvaginal ultrasound or endometrial biopsy) were completed.
Service Type: Diagnostic screening and sampling for uterine malignancy
Typical Site of Service: Outpatient clinics, ambulatory surgical centers, gynecology offices, and imaging centers
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 58-year-old postmenopausal woman presents to a gynecology clinic with abnormal uterine bleeding and an enlarged endometrial stripe on transvaginal ultrasound. The clinician documents that a targeted evaluation for uterine malignancy was performed, including review of risk factors, transvaginal pelvic ultrasound images, and an endometrial sampling (office endometrial biopsy) with specimens submitted to pathology. The workflow includes history and focused physical exam, ordering and performing ultrasound (if not already completed), obtaining endometrial tissue, documenting informed consent and the nature of the sampling procedure, labeling and sending specimens to pathology, and recording results and follow-up plans. The documentation specifically records that screening for uterine malignancy was completed and that an ultrasound and/or endometrial sampling was performed, matching the requirements for billing under G9618.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when the work required to document or perform additional diagnostic evaluation for uterine malignancy is substantially greater than typical |
23 |