2025 HCPCS code G9050
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Oncology Medicare Demonstration Projects Feed
This HCPCS code reports the primary focus of an evaluation and management (E/M) visit for a cancer patient, including work-up, evaluation, or staging at diagnosis or recurrence.
Modifiers may be applicable depending on the specific services performed during the visit. Consult the appropriate coding guidelines for modifier usage.
Medical necessity is established by the presence of a cancer diagnosis or recurrence, requiring a comprehensive evaluation and management visit by a qualified hematology-oncology specialist.The visit must address specific aspects of diagnosis, staging, treatment planning, or disease management. The documentation must support the medical necessity and the use of this code within the context of the Medicare demonstration project.
The clinical responsibility rests with a hematology-oncology specialist.The physician conducts a comprehensive assessment of the patient's cancer, including history, physical examination, ordering and interpreting diagnostic tests, and determining the stage and extent of the disease. They may also discuss treatment options and coordinate care.
In simple words: This code tells Medicare about a doctor's visit focused on a cancer patient's checkup, tests, or determining the extent of their cancer.It's only used for a specific Medicare study, and the doctor must also use other codes to fully describe the visit.
HCPCS code G9050 is used to report the primary focus of an evaluation and management (E/M) visit for a cancer patient.This code is specifically for use within a Medicare-approved demonstration project and signifies a work-up, evaluation, or staging of the patient's cancer at the time of diagnosis or recurrence.The provider must report this code along with CPT codes for the visit's primary focus, disease status, and guideline adherence.Participation is limited to hematology-oncology specialists treating Medicare patients not enrolled in Medicare Advantage plans. This code is used for oncology work-up visits where the provider evaluates or reevaluates the patient before or after a treatment course or contemplated treatment course for cancer.
Example 1: A 65-year-old male presents with newly diagnosed lung cancer.The oncologist performs a comprehensive evaluation, including a thorough history, physical examination, and orders imaging studies (CT scan, PET scan).G9050 is reported for the primary focus of this initial evaluation, along with appropriate CPT codes for the specific services performed., A 72-year-old female with metastatic breast cancer is seen for a follow-up appointment after completing chemotherapy.The oncologist assesses the patient's response to treatment, orders blood tests, and discusses potential next steps in treatment. G9050 is used for the visit's primary focus of reassessing the cancer's status., A 58-year-old male has a recurrence of colon cancer after several years of remission.The oncologist performs a detailed evaluation, including a review of past medical records, physical exam, and diagnostic imaging, to determine the extent of the recurrence. G9050 is reported as the primary focus of this visit, alongside codes for the diagnostic tests and evaluation services.
Thorough documentation is required, including a detailed history and physical examination, results of all diagnostic tests, staging information, discussion of treatment options, and the specific guidelines consulted (e.g., ASCO or NCCN guidelines). The documentation must support the medical necessity for the visit and clearly demonstrate adherence to the specified guidelines for the Medicare demonstration project.
** This code is only valid for use within a specific Medicare demonstration project.Reimbursement and coding practices are governed by the rules of that project.Always refer to the official guidelines for the current project status and requirements.
- RVU: Not specified in provided data. RVUs and reimbursement are subject to Medicare's demonstration project guidelines and may vary.
- Global Days : Not applicable; this is an evaluation and management code, not a surgical procedure.
- Payment Status: Active (within the context of the Medicare demonstration project)
- Modifier TC rule: Not applicable; this is not a procedure that has a technical component.
- Fee Schedule : Fee schedules for G9050 are subject to the specific rates set by Medicare within the confines of its demonstration project. Historical fee information should be obtained from the Medicare demonstration project records.
- Specialties:Hematology-Oncology
- Place of Service:Office