2025 HCPCS code G9061

Available practice guidelines do not address the patient's specific cancer condition.

This code should only be used in conjunction with other required CPT codes for the visit and within the context of the Medicare demonstration project.

Medical necessity is established by demonstrating that the patient's condition is not adequately addressed by existing guidelines, and the chosen treatment is appropriate for the individual circumstances.The documentation should clearly support the medical necessity of the deviation.

Hematology/oncology specialists participating in the Medicare demonstration project are responsible for reporting this code along with appropriate CPT codes. This involves documenting the rationale for deviating from standard guidelines based on the patient's unique circumstances.

IMPORTANT Related codes for primary purpose of visit (G9050-G9055), guideline adherence (G9056-G9062), and disease status (G9063-G9130).

In simple words: This code is used when a cancer patient's situation isn't covered by the usual guidelines, meaning the doctor has to make treatment decisions based on the patient's specific needs.

This code is used for a Medicare demonstration project for patients with cancer where existing guidelines (G9050-G9054) do not address the patient's specific condition. It should be reported alongside CPT codes for the primary focus of the visit, disease status, and guideline adherence by hematology/oncology specialists treating Medicare patients (excluding Medicare Advantage). It indicates that the services provided differ from standard guidelines due to the unique nature of the patient's cancer and current disease status.

Example 1: A patient with a rare form of leukemia receives a treatment regimen not explicitly covered by existing guidelines. The oncologist uses G9061 to indicate the deviation., A patient with breast cancer has a complex medical history that precludes the standard chemotherapy protocol. G9061 is used to document the adjusted treatment plan., A patient with advanced lymphoma undergoes a novel clinical trial treatment. The hematologist uses G9061 to report the treatment, which falls outside established guidelines.

Documentation should include details of the patient's condition, the rationale for deviating from established guidelines, the specific treatment provided, and the expected outcome. Supporting documentation such as pathology reports, imaging studies, and consultation notes may also be required.

  • Payment Status: Unknown
  • Specialties:Hematology, Oncology
  • Place of Service:Office
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