Summary & Overview

HCPCS G9627: No Bladder Injury Identified up to 30 Days Post-Surgery

HCPCS Level II code G9627 documents that a patient did not sustain a bladder injury during surgery and none was identified within 30 days postoperatively. This status code is used to capture a negative postoperative complication finding related to bladder integrity, an important quality and safety marker in procedures with potential pelvic or lower abdominal exposure. Nationally, standardized documentation of absence of specific complications supports claims clarity, quality measurement, and postoperative surveillance.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what the code represents, typical service settings where it applies, and the clinical context for use. The publication outlines benchmarks and policy-relevant considerations for payers and providers, clarifies documentation practices, and summarizes the clinical scenario underpinning the code. It also flags where input data were unavailable for certain fields and directs readers to the sections covering modifiers, related codes, and payer-specific policies. This resource is intended for national audiences involved in coding, billing, surgical quality programs, and payer policy development.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9627HCPCS Level IIpostoperative-statussurgical-qualitybladder-injurysurgical-complicationsambulatory-surgeryhospital-inpatient

Billing Code Overview

HCPCS Level II code G9627 indicates that a patient did not sustain a bladder injury at the time of surgery nor had such an injury discovered subsequently up to 30 days post-surgery. This code documents a negative postoperative finding related to bladder integrity following a surgical procedure.

Service type: Postoperative complication status reporting
Typical site of service: Hospital inpatient or outpatient surgical settings, including ambulatory surgery centers, where bladder injury risk is assessed during and after operative care.

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Clinical & Coding Specifications

Clinical Context

A typical patient scenario involves a 45-year-old female undergoing a planned laparoscopic hysterectomy for symptomatic uterine fibroids. The operative team documents no intraoperative bladder injury and the patient has an uncomplicated immediate postoperative course. During the hospital stay and subsequent follow-up visits through 30 days post-surgery there are no signs or diagnostic findings (urinary leakage, hematuria, fistula, or imaging evidence) suggesting bladder trauma. The clinical workflow includes preoperative evaluation and informed consent, intraoperative cystoscopic inspection when indicated, standard postoperative monitoring of urinary output and symptoms, and scheduled outpatient follow-up at 1–2 weeks and again by 30 days to assess wound healing and urinary function. Documentation explicitly noting absence of bladder injury at time of surgery and up to 30 days post-op supports reporting of G9627. The typical site of service is an inpatient hospital or ambulatory surgery center where pelvic surgery is performed.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than usually required for the procedure (rare for this code).
`23`	Unusual anesthesia	Use when general anesthesia is medically contraindicated and alternative is used (applicable to anesthesia-related billing).
`52`	Reduced services	Use when the procedure is partially reduced or not completed.
`53`	Discontinued procedure	Use when the procedure is started but halted due to extenuating circumstances.
`54`	Surgical care only	Use when reporting only the surgeon's intraoperative portion separate from pre/post-op care.
`55`	Postoperative management only	Use when reporting only post-op care separate from the operative service.
`56`	Preoperative management only	Use when reporting only pre-op evaluation/management.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions.
`AS`	Ambulatory surgery center payment	Use to indicate the service was performed in an ASC setting.
`CO`	Resuscitative services	Use for resuscitative services provided in the ED or perioperative period (payer-specific).
`CQ`	Service furnished under an IHS or Tribal/US Territory contract	Use when services are furnished under these agreements.
`FX`	Primary surgeon	Use to identify the primary surgeon in a multiple-surgeon setting.
`QX`	Assistant surgeon – advanced practice clinician	Use to indicate an APRN/PA acted as an assistant when allowed.
`QY`	Telementoring	Use when the service involved telementoring by a physician during the procedure.

Taxonomy Code	Specialty	Notes
207V00000X	Obstetrics & Gynecology	Gynecologic surgeons who perform hysterectomy and pelvic surgery.
208000000X	General Surgery	General surgeons who perform pelvic and abdominal procedures that may risk bladder injury.
208600000X	Urology	Urologists manage intraoperative detection and repair of urinary tract injuries.
363LP0800X	Anesthesiology	Anesthesiologists providing perioperative care and anesthesia management.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.	Data not available in the input.	Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`58150`	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)	A common primary operative procedure after which documentation of no bladder injury may be reported with `G9627` when no injury is present.
`58570`	Laparoscopic hysterectomy, for uterus 250 g or less, with or without removal of tube(s), with or without removal of ovary(s)	Minimally invasive alternative; intraoperative cystoscopic inspection or documentation of no bladder injury supports `G9627`.
`52000`	Cystourethroscopy, diagnostic, with or without collection of specimen(s) by brushing or washing	Performed intraoperatively or postoperatively when bladder injury is suspected; absence of injury after inspection supports `G9627`.
`51700`	Measurement of urinary residual, bladder catheterization; single determination	Used postoperatively to evaluate voiding function; normal findings consistent with no bladder injury.
`51701`	Measurement of urinary residual, bladder catheterization; first determination	Similar use for postoperative assessment of urinary retention or injury.