Summary & Overview
HCPCS G9676: Diabetes Patient LDL-C 70–189 mg/dL
HCPCS Level II code G9676 designates patients aged 40–75 with type 1 or type 2 diabetes whose highest fasting or direct LDL-C measurement in the measurement year or the two years prior falls between 70 and 189 mg/dL. The code is used in quality measurement to identify a specific LDL-C range relevant to lipid management and risk stratification for people with diabetes. Nationally, this measure informs population health monitoring and payer quality programs focused on cardiovascular risk reduction among adults with diabetes.
Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find clinical context for the LDL-C range, the service type (laboratory result capture for quality measurement), and the typical ambulatory and outpatient laboratory settings where these results are obtained. The publication outlines how the code is used in reporting and quality measurement, describes expected data elements and limitations, and highlights implications for payers and care delivery organizations tracking lipid control in diabetes populations. Data not available in the input will be identified where applicable.
Billing Code Overview
HCPCS Level II code G9676 identifies patients aged 40 to 75 years at the beginning of the measurement period who have type 1 or type 2 diabetes and whose highest fasting or direct laboratory LDL-C result in the measurement year or during the two years prior is between 70–189 mg/dL. This code represents a population-level laboratory result flag used in quality measurement and reporting.
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Service type: Laboratory result capture / quality measurement
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Typical site of service: Outpatient laboratory or ambulatory care setting where fasting or direct LDL-C testing is performed and recorded
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient with a 10-year history of type 2 diabetes presents for an annual chronic disease management visit at a primary care clinic. The patient’s medical record shows ongoing statin therapy and cardiovascular risk assessment. During the encounter, the clinician orders a fasting lipid panel. The laboratory reports an LDL-C of 132 mg/dL, recorded as the highest fasting or direct LDL-C result within the measurement year. The clinical workflow includes: ordering the lipid test, lab specimen collection (fasting or non-fasting depending on ordering preference), result entry into the electronic health record, verification by the clinician, and abstraction into performance reporting. This billing code, G9676, is used to capture the performance measure for patients aged 40–75 years with type 1 or type 2 diabetes who have an LDL-C result of 70–189 mg/dL recorded either in the measurement year or during the two years prior to the start of the measurement period. Typical sites of service are outpatient primary care clinics, endocrinology clinics, and ambulatory laboratory services. Typical patient scenario: adult patient with diabetes scheduled for a routine diabetes management visit who completes a fasting lipid panel and whose LDL-C result falls within the specified 70–189 mg/dL range, meeting the measure criteria for reporting.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services |