2025 HCPCS code G9051
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Evaluation and Management - Oncology Procedures / Professional Services Feed
This HCPCS code reports the primary focus of an evaluation and management (E/M) visit for a cancer patient, where the provider makes treatment decisions, discusses options, and manages cancer-directed therapy.
Modifiers may be applicable depending on the circumstances of the visit.Consult the official HCPCS and CPT modifier guidelines for appropriate modifier usage.
Medical necessity is established by documenting the need for the oncologist's expertise in evaluating the patient's disease, making treatment decisions, and managing the complexities of cancer care.The documentation must demonstrate that the visit was essential for managing the patient's condition and that the services provided were reasonable and necessary. This often involves showing the progression or stability of disease, the need for treatment changes, or adverse effects needing management.
The clinical responsibility rests with the hematologist/oncologist who performs the E/M visit, makes treatment decisions, and manages the patient's cancer care.
In simple words: This code is used by doctors specializing in cancer treatment to bill for a visit where they discuss and decide on a cancer treatment plan with their patient.This includes talking about treatment options, giving treatment, or checking how the treatment is working. It's part of a special Medicare study.
HCPCS code G9051 is used to report the primary focus of an evaluation and management (E/M) visit for a cancer patient. During this visit, the provider makes treatment decisions after staging or restaging the disease, discusses treatment options with the patient, supervises or coordinates active cancer-directed therapy, or manages the effects of the therapy.This code is part of a Medicare-approved demonstration project (started in 2006) requiring reporting alongside CPT codes indicating the visit's primary focus, disease status, and adherence to practice guidelines.Only hematology/oncology specialists treating Medicare patients (not in Medicare Advantage) can use this code. The code is applied when the provider offers, describes, discusses, provides, or evaluates cancer-directed therapy, or alters the patient's treatment plan.Medicare uses such demonstration projects to assess potential program changes and gather data on service delivery, coverage, and payment approaches.
Example 1: A 65-year-old male with metastatic colon cancer presents for a follow-up visit. The oncologist reviews the patient's latest scans, discusses the progression of the disease, and adjusts the chemotherapy regimen based on the findings.Code G9051 is used to report the primary focus of this visit, alongside other CPT codes to represent the specifics of the visit., A 72-year-old female with newly diagnosed breast cancer undergoes a comprehensive initial consultation with her oncologist. The oncologist explains different treatment options (surgery, chemotherapy, radiation), answers the patient's questions, and develops a treatment plan. Code G9051 is used to represent this initial visit., A 58-year-old male with leukemia is hospitalized for severe neutropenia. His oncologist makes daily rounds, monitors his condition, manages his treatment, and coordinates care with other specialists.Each visit during hospitalization where cancer treatment is the primary focus could potentially use G9051.
Detailed clinical notes documenting the encounter, including assessment of the patient's disease status, treatment plan discussion, decision-making process, and any changes to the treatment regimen.Documentation must also support the medical necessity for the visit and clearly show that cancer management was the primary focus.Supporting documentation might include imaging reports, lab results, and progress notes from other treating clinicians.
** This code is specifically for use within the context of a Medicare demonstration project.Proper documentation and adherence to all coding guidelines are critical for accurate reimbursement.Always verify payer-specific billing guidelines and any updates to the demonstration project requirements.
- Revenue Code: Revenue codes will vary depending on the payer and specific services provided.
- RVU: RVUs are not directly assigned to HCPCS codes. Reimbursement is determined by the payer's fee schedule and other factors.
- Global Days : Not applicable.This is an E/M code, not a surgical procedure.
- Payment Status: Active (subject to payer policies and demonstration project requirements)
- Modifier TC rule: Not applicable; this code does not represent a procedure with technical and professional components.
- Fee Schedule : Fee schedules vary by payer and are not consistently available in a historical context. Contact your payer for historical fee information.
- Specialties:Hematology/Oncology
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center