Summary & Overview
HCPCS G9650: Documentation of Therapy Decline or Contraindication
HCPCS Level II code G9650 documents that a patient declined a therapy change or has documented contraindications (such as adverse effects or lack of efficacy) when clinicians evaluate options to improve disease control using measures like PGA, BSA, PASI, or DLQI. This administrative code supports medical record clarity around treatment decisions, informs utilization review, and can affect prior authorization or coverage discussions for advanced or alternative therapies. Nationally, standardized documentation of therapy refusal and contraindications is increasingly important for consistent coverage decisions and for tracking clinical exceptions to guideline-based care.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code's clinical context, service setting, and typical documentation use. The publication also covers benchmarks for documentation prevalence where available, common policy implications for prior authorization and utilization management, and clinical context linking G9650 to dermatology care measures (PGA, BSA, PASI, DLQI). Data not available in the input will be noted where applicable.
Billing Code Overview
HCPCS Level II code G9650 documents that a patient declined a therapy change or has documented contraindications (for example, experienced adverse effects or lack of efficacy with all other therapy options) when assessing options to achieve better disease control as measured by PGA, BSA, PASI, or DLQI.
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Service type: Clinical documentation of therapy refusal or contraindication for disease-control decision-making
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Typical site of service: Outpatient dermatology or specialty clinic visits where chronic dermatologic therapy decisions are made
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 42-year-old patient with chronic plaque psoriasis managed in an outpatient dermatology clinic presents for routine follow-up. The patient has previously tried multiple topical therapies, phototherapy, and several systemic agents but reports intolerable adverse effects or inadequate response. The clinician documents prior therapeutic trials and discusses advanced biologic options. The patient elects to decline further changes in systemic therapy due to prior adverse effects and personal preference. The visit includes disease severity assessment using Physician Global Assessment (PGA), Body Surface Area (BSA), Psoriasis Area and Severity Index (PASI), and Dermatology Life Quality Index (DLQI), and the clinician documents the patient’s informed refusal and/or documented contraindications to alternative therapies to support use of billing code G9650.
Typical clinical workflow:
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The patient checks in for follow-up and completes DLQI questionnaire.
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The dermatologist performs skin exam and documents PGA, BSA, and/or PASI scores.
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The clinician reviews past therapy trials and documents adverse effects, lack of efficacy, or contraindications for other agents.
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The clinician discusses options including escalation to biologic therapy; the patient declines change.
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The clinician documents the informed refusal or contraindications in the medical record and bills
G9650to capture documented decline of therapy change or contraindications when appropriate.
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 if an E/M is performed and documented as distinct from the visit documenting the refusal/contraindication |
59 | Distinct procedural service | Use if another distinct procedure/service is performed that is separate from the documentation supporting G9650 |
24 | Unrelated E/M service by the same physician during a postoperative period | Use when the E/M is unrelated to a prior procedure during global period |
52 | Reduced services | Use when the service performed is partially reduced or not completed (rare for documentation codes) |
53 | Discontinued procedure | Use if a planned therapeutic change was started but discontinued for documented reasons |
57 | Decision for surgery | Use if documentation supports decision for surgical intervention later, separate from decline of medical therapy |
76 | Repeat procedure or service by same physician | Use when the documentation service is repeated during the same encounter series |
77 | Repeat procedure by another physician | Use when another physician repeats documentation or assessment |
90 | Reference (outside) laboratory | Use when outside lab data are referenced to support contraindication (e.g., abnormal labs precluding therapy) |
95 | Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system | Use if the documentation and refusal/contraindication occur via telemedicine visit |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207N00000X | Dermatology | Primary specialty diagnosing and documenting psoriasis severity and therapy decisions |
207E00000X | Allergy & Immunology | May evaluate systemic therapy contraindications or adverse immunologic reactions |
207P00000X | Dermatopathology | Provides diagnostic support when biopsy or pathology informs therapy choices |
2084P0800X | Rheumatology | Involved when psoriatic arthritis or systemic considerations affect therapy selection |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
L40.0 | Psoriasis vulgaris | Primary diagnosis for chronic plaque psoriasis when assessing severity and documenting therapy refusal or contraindications |
L40.9 | Psoriasis, unspecified | Used when psoriasis type not further specified in documentation accompanying G9650 |
L40.8 | Other psoriasis | Applies to less common psoriasis subtypes that may influence therapy choice and contraindications |
M07.0 | Distal interphalangeal psoriatic arthropathy | Psoriatic arthritis diagnosis that may necessitate systemic therapy; documentation of contraindications or refusal is relevant |
M07.3 | Psoriatic spondylitis | Axial involvement impacting systemic therapy decisions and documentation supporting G9650 |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
99213 | Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes | Common E/M level used to document follow-up, assessment of disease severity, therapy discussion, and patient refusal supporting G9650 |
99214 | Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes | Used when a more complex follow-up visit is required with comprehensive documentation of prior therapy trials and contraindications |
11102 | Tangential biopsy of skin (e.g., shave), single lesion | May be performed to confirm diagnosis or rule out alternate pathology prior to systemic therapy decisions |
88305 | Level IV surgical pathology, gross and microscopic examination | Pathology reporting that can influence therapy choice and support documentation of contraindications |
99443 | Telephone evaluation service by physician or other qualified health care professional, 21-30 minutes of medical discussion | Used when therapy discussion and documented refusal occur via extended telephone encounter |