Summary & Overview
HCPCS S9986: Not Medically Necessary Service, Patient Informed
HCPCS Level II code S9986 is used to indicate that a service provided was not medically necessary and that the patient was informed of this status. Nationally, this code matters because it documents patient awareness in situations where services fall outside coverage or medical necessity policies, affecting claims adjudication, member communications, and administrative records. The code is relevant across payers and care settings where elective, optional, or non-covered services are performed.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical and administrative context for use of the code, typical sites of service where it appears, and the implications for claims handling and documentation. The publication covers benchmarks and coding practice patterns, policy considerations related to recording patient awareness of non-medically necessary care, and concise guidance on documentation elements that payers commonly expect. Data not available in the input is identified where applicable.
Billing Code Overview
HCPCS Level II code S9986 denotes a not medically necessary service where the patient is aware that the service is not medically necessary. This entry documents encounters in which a service is provided despite recognition that it lacks medical necessity and the patient has been informed of that status.
-
Service type: Administrative/authorization status indicator documenting patient awareness of non-medically necessary service
-
Typical site of service: Ambulatory clinic, outpatient facility, or other sites where elective or non-covered services may be delivered
Data not available in the input for associated taxonomies, ICD-10 diagnoses, or related codes.
Clinical & Coding Specifications
Clinical Context
A patient requests an elective service that their insurer considers not medically necessary. The clinical workflow begins when a patient calls or is seen in clinic requesting an intervention (for example, an imaging study, durable medical equipment, or an elective procedure) that does not meet payer medical necessity criteria. The ordering clinician documents the patient discussion and the patient’s informed preference to proceed despite lack of medical necessity. Front‑desk or billing staff assign HCPCS code S9986 to indicate the service was provided with the patient aware it is not medically necessary. Typical documentation includes: clinical indication, prior authorization status (if any), documented counseling that the service is not covered as medically necessary, patient acknowledgement or signed waiver, and the service date and site.
Typical site of service: outpatient clinic, ambulatory surgery center, or radiology/imaging center where elective, non‑covered services are delivered. Typical patient scenario: an adult patient requests an advanced imaging study for mild, self‑limited back pain that does not meet imaging guidelines; the clinician informs the patient the payer will not reimburse as medically necessary, the patient elects to pay privately, and S9986 is appended to the claim to denote the patient was informed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
23 |