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    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g9916-functional-status-assessment-once-in-12-months
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    HCPCS G9916: Functional Status Assessment, Annual

    HCPCS Level II code G9916 describes a functional status assessment performed once in the last 12 months, representing a documented evaluation of a patient’s ability to perform activities and functional tasks; the service type is functional status assessment and the typical site of service is outpatient or ambulatory clinical settings where periodic functional evaluations are conducted.

    For related coverage guidance, see recent payer policy updates: Esophagogastroduodenoscopy (EGD) Coverage Policy, Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD), Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease.

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient is an older adult or adult with chronic medical conditions presenting for an annual visit during which clinicians assess functional status to document the patient’s ability to perform activities of daily living and instrumental activities of daily living. The service G9916 is completed once in the last 12 months and is commonly performed by a primary care physician, geriatrician, nurse practitioner, or physician assistant during an outpatient visit or a home health assessment. The clinical workflow includes: an intake interview and brief standardized screening (for example, questions about bathing, dressing, transferring, continence, feeding, shopping, medication management, and transportation); observation or patient/caregiver report when needed; documentation of findings and impact on care plan; and incorporation of results into problem list, referrals (physical therapy, occupational therapy, home health), durable medical equipment orders, or advance care planning as appropriate. Typical sites of service include outpatient clinic, home health visit, or long-term care facility visit. Common patient reasons for the assessment include progressive frailty, new functional decline after hospitalization, medication-related impairment, fall risk, or routine annual assessment for chronic disease management.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99406Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutesOften performed during the same outpatient visit when counseling is delivered alongside functional status evaluation.
    99406Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutesDuplicate entries are not allowed — see note: Data not available in the input.
    99497Advance care planning including explanation and discussion of advance directives, first 30 minutesMay be performed in the same visit when functional decline prompts goals-of-care discussion.
    97110Therapeutic exercises to develop strength and endurance, range of motion and flexibilityOrdered or performed after functional status assessment to address identified deficits.
    97530Therapeutic activities, direct (one-on-one) patient contact by the providerPerformed by occupational therapy to address ADL deficits identified in the functional assessment.
    G0156Services of home health aide, per 15 minutes (when applicable)May be initiated after a home-based functional assessment documenting need for home support services.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    207Q00000XFamily Medicine PhysicianFamily Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadt…
    207R00000XInternal Medicine PhysicianA physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    3336C0003XCommunity/Retail PharmacyA pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance wit…
    207LP4000XPhysician Nutrition Specialist (Anesthesiology)A physician who specializes in the diagnosis and treatment of primary nutritional diseases (e.g., undernutrition, overnutrition, and genetic or acquir…
    376G00000XNursing Home AdministratorAn individual, often licensed by the state, who is responsible for the management of a nursing home.
    2081S0010XSports Medicine (Physical Medicine & Rehabilitation) PhysicianA physician who specializes in Sports Medicine is responsible for continuous care related to the enhancement of health and fitness as well as the prev…
    2081P0301XBrain Injury Medicine (Physical Medicine & Rehabilitation) PhysicianA Brain Injury Medicine physician specializes in disorders of brain function due to injury and disease. These disorders encompass a range of medical,…

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 3

    10 rows

    PolicyPayerEffective Date
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01
    Celiac Disease TestingOscar Health2026-10-01
    Laboratory Testing for the Diagnosis of Inflammatory Bowel DiseaseOscar Health2026-10-01
    Percutaneous Electrical Nerve Field Stimulation (PENFS)Cigna2026-09-15
    Colorectal Cancer ScreeningBlue Cross Blue Shield - New Mexico2026-09-04

    Related Codes

    HCPCS-G9490-HOME-ASSESSMENT-NON-HOMEBOUND

    HCPCS G9490: Home Visit Patient Assessment for Non-Homebound Beneficiary

    HCPCS-G0008-INFLUENZA-VACCINE-ADMINISTRATION

    HCPCS G0008: Administration of Influenza Virus Vaccine

    HCPCS-G0009-PNEUMOCOCCAL-VACCINE-ADMINISTRATION

    HCPCS G0009: Administration of Pneumococcal Vaccine

    HCPCS-G0010-HEPATITIS-B-VACCINE-ADMINISTRATION

    HCPCS G0010: Administration of Hepatitis B Vaccine

    HCPCS-G0011-PREP-COUNSELING-HIV-RISK-REDUCTION-ADHERENCE

    HCPCS G0011: Individual PrEP Counseling, HIV Risk Assessment

    HCPCS-G0012-PRE-EXPOSURE-PROPHYLAXIS-INJECTION-HIV-PREVENTION

    HCPCS G0012: Injection of PrEP Drug for HIV Prevention

    HCPCS-G0013-PREP-INDIVIDUAL-COUNSELING-HIV-RISK-REDUCTION

    HCPCS G0013: Individual PrEP Counseling by Clinical Staff

    HCPCS-G0017-PSYCHOTHERAPY-CRISIS-FIRST-60-MINUTES-NON-OFFICE

    HCPCS G0017: Psychotherapy for Crisis, First 60 Minutes

    HCPCS-G0018-PSYCHOTHERAPY-CRISIS-ADDITIONAL-30-MINUTES-NON-OFFICE

    HCPCS G0018: Psychotherapy for Crisis, Additional 30 Minutes

    HCPCS-G0019-COMMUNITY-HEALTH-INTEGRATION-SDOH-CARE-COORDINATION

    HCPCS G0019: Community Health Integration, Person-Centered Assessment

    Showing 1–10 of 1996

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    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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