G9940 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS G9940: Documentation of Medical Reason for Not on a Statin

HCPCS Level II code G9940 represents documentation that a patient has a documented medical reason for not receiving a statin when one would otherwise be indicated. The code captures clinically relevant contraindications and intolerances — for example, pregnancy, in vitro fertilization, certain reproductive therapies, end-stage renal disease, cirrhosis, or muscle-related adverse effects — and serves as a structured way to record these exceptions for quality measurement and billing workflows. Nationally, standardized documentation of statin exceptions affects quality reporting, population health management, and payer coverage reviews.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code's clinical context, typical service settings, and the common modifiers associated with this HCPCS Level II code. The publication highlights how G9940 is used in quality reporting and charting to support claims and program-level measures, and it provides benchmarks and policy considerations relevant to payers and ambulatory providers. Data not available in the input regarding associated taxonomies, ICD-10 pairings, or specific payer policy language is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9940HCPCS Level IIstatin contraindicationquality reportingambulatory careclinical documentationmedication exceptionsoutpatient coding

Billing Code Overview

HCPCS Level II code G9940 documents a medical reason for not prescribing a statin when guideline-directed statin therapy is otherwise indicated. Examples include pregnancy, in vitro fertilization, recent or current use of clomiphene, end-stage renal disease, cirrhosis, or muscular pain and muscle disease during the measurement period or the prior year.

Service Type: Clinical documentation of statin contraindication or intolerance

Typical Site of Service: Outpatient clinic, primary care office, cardiology clinic, or other ambulatory care settings

Clinical & Coding Specifications

Clinical Context

A 54-year-old patient with documented atherosclerotic cardiovascular disease (ASCVD) attends a primary care visit for chronic disease management. The clinician reviews the medication list and statin therapy history and documents that the patient is not currently on a statin due to severe statin-associated myopathy and a prior documented creatine kinase elevation during statin exposure. The clinician records the medical reason for not prescribing a statin in the chart, including relevant history, lab results, and shared decision-making discussion. Documentation is coded with G9940 to indicate a valid medical reason for not being on a statin during the measurement period. Typical workflow includes medication reconciliation, review of prior adverse reactions and lab data, problem-list update, and placement of the G9940 code in the encounter or quality report. Typical site of service is an outpatient primary care clinic or cardiology clinic where preventive medication reconciliation and quality reporting occur.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when unusually extensive documentation or additional work is required to justify complexity of decision-making around statin contraindication or alternative therapy discussion.

HCPCS G9038: Specialist Co-Management and Care Planning

HCPCS-G2178-LOWER-EXTREMITY-NEUROLOGICAL-EXAM-NOT-ELIGIBLE

HCPCS G2178: Lower Extremity Neurological Exam — Not Eligible

HCPCS-G2134-FRAILTY-WITH-DEMENTIA-MEDICATION-DISPENSED

HCPCS G2134: Frailty with Dispensed Dementia Medication

HCPCS-G9311-NO-SURGICAL-SITE-INFECTION-POSTOPERATIVE-ASSESSMENT

HCPCS G9311: No Surgical Site Infection

HCPCS-G9911-CLINICALLY-NODE-NEGATIVE-INVASIVE-BREAST-CANCER-T1-T2-N0

HCPCS G9911: Clinically Node-Negative Invasive Breast Cancer (T1/T2)

HCPCS-G2145-OSWESTRY-DISABILITY-INDEX-POSTOP-FUNCTIONAL-ASSESSMENT

HCPCS G2145: Postoperative Oswestry Disability Index Assessment

HCPCS-G6020-COLONOSCOPY-THROUGH-STOMA-STENT-PLACEMENT

HCPCS G6020: Colonoscopy Through Stoma with Transendoscopic Stent Placement

HCPCS-G0141-CERVICAL-VAGINAL-AUTOMATED-CYTOLOGY-SCREENING-MANUAL-RESCREEN

HCPCS G0141: Cervical/Vaginal Automated Cytology Screening with Manual Rescreen

HCPCS-G0451-DEVELOPMENTAL-TESTING-INTERPRETATION-REPORT

HCPCS G0451: Developmental Testing with Interpretation and Report

HCPCS-G2209-PATIENT-REFUSED-TO-PARTICIPATE

HCPCS G2209: Patient Refused to Participate

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`208D00000X`	Family Medicine	Primary outpatient clinicians who reconcile medications and document statin reasons.
`207RC0000X`	Internal Medicine	Internists managing chronic cardiovascular risk and documenting statin contraindications.
`207RP0000X`	Cardiology	Cardiology specialists documenting ASCVD management decisions and statin intolerance.
`363L00000X`	Nurse Practitioner	Advanced practice clinicians who provide medication management and documentation.
`310400000X`	Physician Assistant	PAs who perform medication reconciliation and enter quality codes like `G9940`.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E78.0`	Pure hypercholesterolemia	Indicates elevated cholesterol where statin therapy is usually considered; documentation of not using a statin would reference this diagnosis.
`I25.10`	Atherosclerotic heart disease of native coronary artery without angina pectoris	ASCVD diagnosis that typically requires statin therapy; `G9940` documents a medical reason for absence of statin.
`G72.0`	Drug-induced myopathy	Represents statin-associated myopathy, a common medical reason to document statin nonuse with `G9940`.
`N18.6`	End stage renal disease	ESRD can alter lipid management and is listed as a valid reason for not prescribing statins in the `G9940` description.
`K74.60`	Unspecified cirrhosis of liver	Significant liver disease such as cirrhosis is a medical reason for withholding statin therapy and is captured with `G9940`.

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 visit code used when documenting medication reconciliation and the medical reason for not prescribing a statin with `G9940`.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for more complex visits with detailed review of history, labs, and discussion supporting the `G9940` documentation.
`99406`	Smoking and tobacco-use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Often performed during preventive counseling visits where statin therapy decisions and cardiovascular risk management are addressed alongside `G9940` documentation.
`93000`	Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report	Performed in cardiovascular risk assessment visits that may include documentation of statin nonuse with `G9940`.
`80061`	Lipid panel (total cholesterol, HDL, and triglycerides)	Laboratory assessment commonly ordered before or during discussions that result in documentation of not using a statin coded with `G9940`.

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