Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerBilling CodesTemporary National Codes (Non-Medicare)HCPCS hcpcs-s9986-not-medically-necessary-service-patient-aware
    Ask Trek AI about this page

    HCPCS S9986: Not Medically Necessary Service, Patient Aware

    HCPCS Level II code S9986 indicates a documented service provided when the patient is aware that the service is not medically necessary; the service type is a non–medically necessary patient‑aware encounter, typically occurring in outpatient or ambulatory settings where elective or requested services are declined for medical necessity but still performed with patient acknowledgment.

    For related coverage guidance, see recent payer policy updates: Fixed Wing Air Ambulance Transport, Air Ambulance, Ambulance Services (for New Mexico Only).

    Customize your policy alerts

    Sign up for hcpcs S9986 policy alerts

    Get alerted when payer policies referencing S9986 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Table of contents

    Progress1 / 7

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    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.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    71045Radiologic examination, chest; single view, frontalOften ordered as an imaging service that could be elective and billed with S9986 when patient accepts noncoverage.
    72148Magnetic resonance (MR) imaging, spine, lumbar; without contrastCommon advanced imaging that may be denied as not medically necessary for mild or nonspecific low back pain; patient may elect to proceed.
    20610Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee)Elective joint injections for pain that a payer may deem not medically necessary for certain indications; S9986 documents patient awareness.
    99213Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutesTypical visit where counseling and patient acknowledgement of noncoverage occur before an elective service is provided and billed with S9986.
    99070Supplies and materials (e.g., gloves, bandages), non‑reimbursed itemsAncillary items associated with an elective service that the patient may be charged for when payer denies medical necessity and S9986 is used.

    Related Modifiers

    7 rows

    ModifierDescriptionWhen to Use
    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…
    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…
    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…
    51Modifier –51 (Multiple Procedures) is used when the same provider performs multiple procedures in the same session to identify secondary, non‑exempt procedures and indicate payment reduction logic…- Use modifier -51 when the same provider performs multiple distinct procedures during the same patient encounter: report the highest‑valued procedure first (no modifier) and append -51 to…
    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…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    207P00000XEmergency Medicine PhysicianAn emergency physician focuses on the immediate decision making and action necessary to prevent death or any further disability both in the pre-hospit…
    207L00000XAnesthesiology PhysicianAn anesthesiologist is trained to provide pain relief and maintenance, or restoration, of a stable condition during and immediately following an opera…
    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…
    261Q00000XClinic/CenterA facility or distinct part of one used for the diagnosis and treatment of outpatients. "Clinic/Center" is irregularly defined, sometimes being limite…
    208D00000XGeneral Practice PhysicianA physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.
    225XM0800XMental Health Occupational TherapistOccupational therapists provide treatment for people recovering from a mental or physical illness to regain their independence and stability and to en…
    207WX0009XGlaucoma Specialist (Ophthalmology) PhysicianAn ophthalmologist who specializes in the treatment of glaucoma and other disorders related to increased intraocular pressure and optic nerve damage. …
    251B00000XCase Management AgencyAn organization that is responsible for providing case management services. The agency provides services which assist an individual in gaining access…

    Related ICD-10-CM Codes

    26 rows

    ICD-10-CM CodeDescription
    E11.9Type 2 diabetes mellitus without complications
    E78.5Hyperlipidemia, unspecified
    F32.9Major depressive disorder, single episode, unspecified
    F41.9Anxiety disorder, unspecified
    G43.909Migraine, unspecified, not intractable, without status migrainosus
    I10Essential (primary) hypertension
    J02.9Acute pharyngitis, unspecified
    J44.9Chronic obstructive pulmonary disease, unspecified
    K21.9Gastro-esophageal reflux disease without esophagitis
    L03.90Cellulitis, unspecified

    Showing 1–10 of 26

    Related Payer Policy Updates

    Specialty: Emergency & Medical Transportation1 / 3

    10 rows

    PolicyPayerEffective Date
    Fixed Wing Air Ambulance TransportCigna2026-08-15
    Air AmbulanceAmbetter Georgia2026-08-01
    Ambulance Services (for New Mexico Only)UnitedHealthcare2026-08-01
    Ambulance Services (for Tennessee Only)UnitedHealthcare2026-08-01
    Clinical Policy: Air AmbulanceArizona Complete Health2026-08-01
    Air AmbulanceCentene2026-08-01
    Clinical Policy: Air AmbulanceCentene2026-08-01
    Clinical Policy: Air AmbulanceAmbetter Nevada2026-08-01
    Ambulance TransportProvidence Health Plan2026-07-01
    Air ambulance transport coverage criteriaeocco2026-07-01

    Related Codes

    HCPCS-LEVEL-II-S2152-SOLID-ORGAN-TRANSPLANTATION-GLOBAL-CARE

    HCPCS Level II S2152: Solid Organ Procurement and Transplantation

    HCPCS-LEVEL-II-S2266-INDUCED-ABORTION-29-TO-31-WEEKS

    HCPCS Level II S2266: Induced Abortion, 29 to 31 Weeks

    HCPCS-LEVEL-II-S3630-EOSINOPHIL-COUNT-BLOOD-DIRECT

    HCPCS Level II S3630: Eosinophil Count, Blood, Direct

    HCPCS-LEVEL-II-S4017-INCOMPLETE-ART-CYCLE-CANCELLED-PRIOR-TO-STIMULATION

    HCPCS Level II S4017: Incomplete Cycle — Cancelled Prior to Stimulation

    HCPCS-LEVEL-II-S8055-ULTRASOUND-GUIDANCE-MULTIFETAL-REDUCTION-TC

    HCPCS Level II S8055: Ultrasound Guidance for Multifetal Pregnancy Reduction

    HCPCS-LEVEL-II-S8940-EQUESTRIAN-HIPPOTHERAPY-PER-SESSION

    HCPCS Level II S8940: Equestrian/Hippotherapy, Per Session

    HCPCS-LEVEL-II-S9024-PARANASAL-SINUS-ULTRASOUND

    HCPCS Level II S9024: Paranasal Sinus Ultrasound

    HCPCS-LEVEL-II-S9366-HOME-TPN-1-2L-PER-DAY-HOME-INFUSION

    HCPCS Level II S9366: Home Infusion TPN, 1–2 L/day

    HCPCS-LEVEL-II-S9446-GROUP-PATIENT-EDUCATION-NON-PHYSICIAN

    HCPCS S9446: Patient Education, Non-Physician Provider, Group, Per Session

    HCPCS-LEVEL-II-S9451-EXERCISE-CLASS-NON-PHYSICIAN-SESSION

    HCPCS S9451: Exercise Classes, Non-Physician Provider, Per Session

    Showing 1–10 of 532

    • More pages

    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.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.