Summary & Overview
HCPCS G9633: No Ureter Injury Identified Within 30 Days Post-Surgery
HCPCS Level II code G9633 documents that a patient did not sustain a ureter injury during surgery and none was identified within 30 days postoperatively. Nationally, explicit documentation of absence of specific surgical complications supports quality measurement, care coordination, and accurate reporting of postoperative outcomes. Use of G9633 enables clinicians and hospitals to signal an assessed and confirmed absence of ureteral injury in the immediate and early postoperative window.
Key payers in this national context include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context and typical service settings, comparisons of payer coverage approaches where available, and guidance on common billing considerations associated with codes documenting surgical outcomes. The publication also outlines typical modifiers reported with related services and notes where data is not available in the input.
This summary provides clinicians, coding professionals, and policy analysts with the essential meaning of G9633, its relevance to surgical quality documentation, and what to look for in payer policies and billing patterns when this code appears on the claim or medical record.
Billing Code Overview
HCPCS Level II code G9633 indicates that the patient did not sustain a ureter injury at the time of surgery nor was such an injury discovered subsequently up to 30 days post-surgery. This code documents an absence of ureteral injury in the perioperative and early postoperative period.
Service type: Surgical outcome verification and postoperative complication surveillance.
Typical site of service: Hospital operating room and inpatient or outpatient postoperative care settings, including post-anesthesia recovery and surgical follow-up visits.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult undergoing an abdominal, pelvic, or urologic surgery (for example, hysterectomy, colorectal resection, or complex pelvic adhesiolysis) in an inpatient or ambulatory surgical center setting where the surgeon documents that no ureteral injury occurred during the procedure and none was identified in the subsequent 30-day postoperative period. The clinical workflow includes preoperative imaging or review of prior studies as indicated, intraoperative identification and protection of ureters (visualization, stenting if used), operative note documentation of ureter status, immediate postoperative monitoring for signs of ureteral compromise (flank pain, anuria, rising creatinine, urinary leak), and follow-up visits or communications up to 30 days after surgery confirming absence of ureteral injury. Typical sites of service are hospital operating rooms and ambulatory surgical centers. Common clinicians involved are general surgeons, gynecologic surgeons, urologists, anesthesiologists, and perioperative nursing staff. The scenario reflects a documentation element used for quality reporting and postoperative complication surveillance rather than a billable surgical procedure itself.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work required is substantially greater than usual for the primary procedure (e.g., extensive adhesiolysis to avoid ureteral injury). |