G9938 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS G9938: Institutional SNP Enrollment and Long-Term Care Residency, Age 66+

HCPCS Level II code G9938 designates beneficiaries aged 66 and older who are either enrolled in Institutional Special Needs Plans (SNPs) or who have resided in long-term care facilities (POS 32, 33, 34, 54, or 56) for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period. The code is used to identify a specific, higher-acuity population for measurement and reporting purposes, informing care coordination and quality assessment across payers.

Key payers included in this national overview are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the clinical and administrative scope of G9938, typical sites of service, and the service type reflected by the code. The publication provides context on why accurate designation of long-term institutional residency and SNP enrollment matters for population management, risk stratification, and reporting workflows.

Coverage benchmarks, coding guidance implications, and policy-relevant considerations related to identification of eligible beneficiaries are summarized. Data elements not supplied in the input—such as detailed associated taxonomies, ICD-10 diagnoses, related codes, and service line—are noted as not available.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9938HCPCS Level IIinstitutional SNPlong-term caresenior carepopulation identificationquality measurementplace-of-service

Billing Code Overview

HCPCS Level II code G9938 identifies patients aged 66 or older who are enrolled in Institutional Special Needs Plans (SNPs) or who have resided in long-term care with place-of-service codes 32, 33, 34, 54, or 56 for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period.

Service type: Long-term care residency / institutional SNP enrollment status determination
Typical site of service: Institutional long-term care settings (skilled nursing facilities, nursing facilities, custodial care settings) and Institutional Special Needs Plan enrollment records

Data not available in the input for associated taxonomies, ICD-10 diagnoses, related codes, and service line.

Clinical & Coding Specifications

Clinical Context

A 78-year-old resident of a long-term care facility (place of service code 32) participates in an Institutional Special Needs Plan (SNP). The resident has lived in the facility for more than 90 consecutive days during the six months prior to the measurement period through December 31 of the measurement period. The care team documents enrollment status and residency duration in the electronic health record (EHR) during a routine chronic care management visit. Administrative staff verify eligibility and residency dates from facility intake records and the plan roster. Billing staff assign the HCPCS Level II code G9938 on the claim to indicate the patient meets the measure criteria for institutional SNP or long-term care residency for quality and payment reporting. Common clinical workflow steps include: initial eligibility verification, clinical encounter documentation noting residency duration and plan enrollment, coder review for correct G9938 placement, and claim submission with any applicable modifiers for unusual circumstances (for example, institutional transfer or partial services). Care coordination notes and facility admission records are retained to support claim validation.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS G9873: MDPP First Core Session Attendance

HCPCS-G0512-PSYCHIATRIC-COLLABORATIVE-CARE-RHC-FQHCC

HCPCS G0512: Psychiatric Collaborative Care Model, 60+ Minutes

HCPCS-G9843-RAS-KRAS-NRAS-GENE-MUTATION-TESTING

HCPCS G9843: Ras (KRAS or NRAS) Gene Mutation Testing

HCPCS-G9165-ATTENTION-FUNCTIONAL-LIMITATION-ASSESSMENT

HCPCS G9165: Attention Functional Limitation Assessment, Therapy Episode

HCPCS-G9102-GASTRIC-ADENOCARCINOMA-DISEASE-STATUS-ASSESSMENT

HCPCS G9102: Gastric Adenocarcinoma Disease Status Assessment

HCPCS-G1008-CLINICAL-DECISION-SUPPORT-CRANBERRY-PEAK

HCPCS G1008: Clinical Decision Support Mechanism, Cranberry Peak

HCPCS-G9392-POSTOPERATIVE-REFRACTION-OUTCOME-CATARACT-SURGERY

HCPCS G9392: Postoperative Refraction Not Within ±1 Diopter After Cataract Surgery

HCPCS-G9882-MDPP-ONGOING-MAINTENANCE-SESSIONS-MONTHS-13-15-5PCT-WEIGHT-LOSS

HCPCS G9882: MDPP Ongoing Maintenance Sessions, Months 13–15

HCPCS-G4033-SKILLED-NURSING-FACILITY-MIPS-SPECIALTY-SET

HCPCS G4033: Skilled Nursing Facility MIPS Specialty Set

HCPCS-G8995-THERAPY-DISCHARGE-FUNCTIONAL-LIMITATION

HCPCS G8995: Therapy Discharge Functional Limitation

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who manage chronic care and document SNP residency and eligibility.
`207R00000X`	Internal Medicine	Hospital-based or facility-based internists overseeing complex chronic conditions in long-term care residents.
`331K00000X`	Geriatric Medicine	Specialists focused on elderly care and long-term care population management and documentation.
`207L00000X`	Nurse Practitioner	Advanced practice providers who perform assessments, document residency, and assist with care coordination.
`363A00000X`	Physician Assistant	Clinician extenders who provide routine visits and documentation for facility residents.

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.	Data not available in the input.	Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99304`	Initial nursing facility care, per day, for the evaluation and management of a patient, typically 30 minutes	Often billed when a new long-term care resident is evaluated and residency status is documented for reporting such as `G9938`.
`99307`	Nursing facility services, subsequent, per day, for the evaluation and management of a patient, typically 25 minutes	Used for follow-up facility visits where continued residency and care needs are documented alongside eligibility reporting.
`99490`	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	May be performed for eligible long-term care residents and documented in the care plan that supports reporting with `G9938`.
`99487`	Complex chronic care management services, first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	Used when higher complexity care coordination is provided for institutional residents and documentation supports quality reporting.
`G0463`	Hospital outpatient clinic visit for assessment and management of a patient	Applicable when facility-based outpatient clinics assess residents and document long-term care residency for quality measures.

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