Summary & Overview
HCPCS G9619: Documentation of Reason for Not Screening for Uterine Malignancy
HCPCS Level II code G9619 denotes documentation of the reason(s) a patient was not screened for uterine malignancy, such as a prior hysterectomy. This administrative code captures clinical exclusion criteria or patient-specific factors that preclude standard uterine cancer screening and supports accurate reporting of preventive care delivery. Nationally, clear documentation of screening exceptions matters for quality measurement, performance reporting, and accurate interpretation of screening rates.
Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical purpose and typical use cases across outpatient and ambulatory settings, guidance on how the code fits into documentation workflows, and discussion of where this code matters for quality metrics and claims records. The publication also outlines common reporting contexts and highlights limitations in available auxiliary data.
The report does not provide clinical guidance or payer-specific billing instructions. Data not available in the input are noted where applicable. The article equips policy, compliance, and clinical documentation stakeholders with the context needed to interpret use of G9619 in national reporting and administrative datasets.
Billing Code Overview
HCPCS Level II code G9619 documents the reason(s) for not screening for uterine malignancy (for example, prior hysterectomy). This code is used when a clinician records why a patient did not receive a recommended uterine cancer screening during an eligible encounter.
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Service type: Clinical documentation of screening avoidance or exclusion criteria related to uterine malignancy screening
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Typical site of service: Outpatient clinical settings where preventive screening decisions and documentation occur, such as primary care clinics, gynecology offices, and ambulatory care centers
Clinical & Coding Specifications
Clinical Context
A 62-year-old female presents to a gynecology clinic for a routine preventive visit. She has a documented history of total abdominal hysterectomy for benign uterine fibroids 10 years prior and no cervical stump. The office clinician performs a chart review and patient interview, confirms the prior hysterectomy through operative note or history, and documents that uterine malignancy screening (e.g., endometrial biopsy or transvaginal ultrasound for endometrial evaluation) is not applicable. The clinician records the reason for not screening for uterine malignancy as “prior hysterectomy” and includes the relevant supporting documentation (operative report, patient statement, or prior surgical history) in the medical record. The workflow includes verifying the hysterectomy in the electronic health record, counseling the patient as needed about ongoing gynecologic health, and coding the encounter with billing code G9619 to indicate documentation of the reason(s) for not screening for uterine malignancy.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when a distinct E/M is provided in addition to the documentation for not screening and meets E/M criteria |