Summary & Overview
HCPCS G9667: Documentation of Medical Reason for Not Using Statin Therapy
HCPCS Level II code G9667 captures documentation of medical reasons why a patient is not currently using statin therapy or has not received an order for it. This code standardizes reporting of clinical exceptions such as adverse effects, allergy or intolerance, pregnancy or breastfeeding, palliative care status, active liver or hepatic insufficiency, end-stage renal disease, and cases where patients with diabetes have LDL-C < 70 mg/dL and are not on statins. Nationally, consistent use of G9667 supports quality measurement, claims clarity, and accurate reflection of appropriate clinical decision-making when statin treatment is contraindicated or intentionally deferred.
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, guidance on typical sites of service, and discussion of how the code relates to quality documentation and claims reporting. The publication also outlines what to expect in payer coverage patterns and benchmarking implications where available. Data not available in the input is noted where specific payer policies, modifiers, associated taxonomies, ICD-10 pairings, related codes, and line-item billing details are not provided.
Billing Code Overview
HCPCS Level II code G9667 documents the medical reason(s) why a patient is not currently a statin therapy user or has not received an order (prescription) for statin therapy. Examples include adverse effects, allergy or intolerance to statin medications; active pregnancy or breastfeeding; receipt of palliative care; active liver disease, hepatic insufficiency, or end-stage renal disease (ESRD); and patients with diabetes who have fasting or direct LDL-C laboratory results below 70 mg/dL and are not taking statin therapy.
Service Type: Clinical documentation of medical justification for non-use of statin therapy.
Typical Site of Service: Outpatient ambulatory care settings, primary care offices, specialty clinics (e.g., cardiology, endocrinology), and other clinical encounters where medication reconciliation and treatment decisions are documented.
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with a history of atherosclerotic cardiovascular disease (prior myocardial infarction) presents for a chronic care visit. The clinician reviews medications and documents that the patient is not currently taking statin therapy because of a documented severe statin-associated myopathy with persistent symptoms despite trial of multiple agents, and the patient has a recorded intolerance and allergy to multiple statins. The clinician records the medical reason(s) for not being a statin therapy user and documents recent fasting LDL-C of 65 mg/dL. The workflow includes chart review of past adverse reactions, review of recent laboratory results, assessment of pregnancy/breastfeeding status if applicable, review for active hepatic disease or end-stage renal disease, and entry of the rationale into the problem list and progress note. This documentation supports reporting of G9667 to indicate medical reasons for not prescribing or ordering statin therapy at this time.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service on the same day | Use when an E/M visit is performed in addition to documentation qualifying for G9667 and is separate from counseling about statin nonuse. |
59 | Distinct procedural service | Use when another distinct service on the same day is unrelated to the statin nonuse documentation and must be reported separately.
24 | Unrelated E/M service during a postoperative period | Use if the statin nonuse documentation occurs during a postoperative global period and is unrelated to the surgery.
GR | Directs that services are related to COVID-19 testing (CMS G modifier historically) | Not typically used; included only if local payer requires COVID-related modifier for services tied to testing and documentation policies.
KX | Requirements specified in a medical policy have been met | Use when a payer requires attestation that documentation meets policy conditions for statin therapy exceptions.
JW | Drug amount discarded/not administered to patient | Rarely applicable; included only when documentation references discarded statin doses in inventory records (uncommon for this code).
GA | Waiver of liability statement on file | Use if patient refuses statin therapy after counseling and provider files a waiver of liability required by a payer.
GZ | Item or service expected to be denied as not reasonable and necessary | Use when documentation indicates medical reason but payer requires reporting of anticipated denial status.
TC | Technical component | Use when a related laboratory test (LDL-C) technical component is billed separately by a lab.
26 | Professional component | Use when provider bills for the professional component of a lab or diagnostic service associated with evaluating statin contraindications.
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207Q00000X | Cardiovascular Disease (Cardiologist) | Cardiologists commonly document decisions about lipid management in complex ASCVD patients. |
207RC0000X | Internal Medicine | Primary care/internal medicine physicians frequently document statin nonuse reasons during chronic care visits.
207P00000X | Family Medicine | Family physicians manage preventive cardiovascular therapies and document statin contraindications or intolerances.
208D00000X | Geriatric Medicine | Geriatricians often document medication intolerance or goals of care (e.g., palliative situations) leading to nonuse.
363L00000X | Clinical Pharmacy | Clinical pharmacists document medication intolerance assessments and recommendations related to statin therapy.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
E78.5 | Hyperlipidemia, unspecified | Commonly associated with lipid management decisions; documentation of nonuse may reference underlying dyslipidemia. |
I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris | Patients with ASCVD are primary candidates for statin therapy; this code is relevant when documenting reasons for not prescribing statins.
O99.32 | Liver disorder in pregnancy, not elsewhere classified | Pregnancy-related liver disease influences decisions to withhold statin therapy.
K71.7 | Toxic liver disease with chronic persistent hepatitis | Active hepatic disease is a listed medical reason to avoid statin therapy.
N18.6 | End stage renal disease | ESRD is a listed condition that may influence statin prescribing and is relevant for documentation of nonuse.
O09.611 | Supervision of high-risk pregnancy, first trimester | Pregnancy status requires documentation if statins are withheld.
Z88.0 | Allergy status to penicillin (example allergy code) | Allergy/intolerance codes document patient-reported adverse reactions; a specific code for statin allergy would be used if available.
Z79.899 | Other long term (current) drug therapy | Used to document long-term medication decisions, including documentation of therapy nonuse and reasons.
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 | Commonly performed when documenting medical reasons for not using statin therapy as part of an E/M visit. |
99406 | Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes | May be performed in the same visit addressing cardiovascular risk modification alongside statin nonuse documentation.
80061 | Lipid panel (total cholesterol, HDL cholesterol, and triglycerides) | Laboratory testing used to document LDL-C levels that can support rationale for not prescribing statin therapy (e.g., LDL-C < 70 mg/dL).
82465 | Cholesterol, direct, LDL | Direct LDL-C testing used to document low LDL-C values supporting nonuse of statin therapy.
99497 | Advance care planning including the explanation and discussion of advance directives | May be part of visits where goals of care or palliative status justify withholding statin therapy.