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    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-level-ii-g8509-positive-pain-assessment-no-follow-up-plan
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    HCPCS G8509: Positive Pain Assessment, No Follow-Up Plan Documented

    HCPCS Level II code G8509 documents a positive pain assessment using a standardized tool where a follow-up plan is not documented and no reason is given; this code captures the clinical finding (positive pain screen) and absence of a documented care plan, typically recorded as part of pain screening and assessment workflows in ambulatory or inpatient clinical settings such as primary care clinics, specialty outpatient practices, emergency departments, or hospital wards.

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    Table of contents

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    Clinical & Coding Specifications

    Clinical Context

    A 68-year-old patient with chronic osteoarthritis of the knee presents to a primary care clinic for routine follow-up. During the visit the clinician documents that the patient reports significant pain using a standardized assessment tool (for example, a numeric rating scale or Brief Pain Inventory) and the assessment is recorded as positive for clinically significant pain. The record documents the positive score and the assessment tool used but does not include a documented follow-up plan or a documented reason why no plan was recorded. Typical workflow: patient screening or nurse intake includes a standardized pain screen; clinician reviews results, confirms positive pain assessment, documents assessment tool and score in the medical record. If a treatment plan is developed, separate orders, medication management, or referrals are documented and coded; when no plan is documented and no justification is given, the encounter may warrant reporting of G8509 to indicate a positive pain assessment without a documented follow-up plan or reason.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesCommon E/M code for outpatient visits where a standardized pain assessment is performed and documented.
    99406Smoking and tobacco-use cessation counseling, intermediate, greater than 3 minutes up to 10 minutesExample of a counseling add-on often documented in primary care visits alongside pain assessment when behavioral factors are addressed.
    96127Brief emotional/behavioral assessment (e.g., depression screen), per standardized instrumentOften performed alongside pain screening to assess psychosocial contributors to pain; positive screens may prompt further evaluation.
    99490Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar monthMay be relevant when chronic pain is documented and a longitudinal care plan is established following assessment.
    97110Therapeutic exercises to develop strength and endurance, range of motion and flexibilityA common non-pharmacologic treatment ordered after a positive pain assessment when a follow-up plan is implemented.

    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…
    208000000XPediatrics PhysicianA pediatrician is concerned with the physical, emotional and social health of children from birth to young adulthood. Care encompasses a broad spectru…
    2086S0102XSurgical Critical Care PhysicianA surgeon with expertise in the management of the critically ill and postoperative patient, particularly the trauma victim, who specializes in critica…
    2472D0500XDarkroom TechnicianNone
    261QA0006XAmbulatory Fertility FacilityA fertility facility, which may be licensed, registered, or certified in some states, that is not hospital-based, where services are provided at a fi…
    207ZF0201XForensic Pathology PhysicianA forensic pathologist is expert in investigating and evaluating cases of sudden, unexpected, suspicious and violent death as well as other specific c…
    3104A0625XAssisted Living Facility (Mental Illness)A facility providing supportive services to individuals who can function independently in most areas of activity, but need special guidance, assistanc…

    Related ICD-10-CM Codes

    25 rows

    ICD-10-CM CodeDescription
    G43.909Migraine, unspecified, not intractable, without status migrainosus
    G44.209Tension-type headache, unspecified, not intractable
    G89.4Chronic pain syndrome
    M17.9Osteoarthritis of knee, unspecified
    M19.90Unspecified osteoarthritis, unspecified site
    M25.50Pain in unspecified joint
    M47.816Spondylosis without myelopathy or radiculopathy, lumbar region
    M51.26Other intervertebral disc displacement, lumbar region
    M54.12Radiculopathy, cervical region
    M54.13Radiculopathy, cervicothoracic region

    Showing 1–10 of 25

    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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