G9616 – Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient with a gynecologic or other pelvic malignancy noted at the time of surgery)

Long description

Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient with a gynecologic or other pelvic malignancy noted at the time of surgery)

Short description

Doc rsn no preop assmt

Pricing indicator

00 Not separately priced by Part B (bundled, not covered or Part A only)

Medicare coverage

C Carrier judgment – coverage decided by the Medicare contractor

BETOS category

Z2 Undefined codes

Added

January 1, 2016

Last change

January 1, 2021 – No change

Termination date

December 31, 2020

Nearby G codes

• G9608 – Intraoperative cystoscopy not performed to evaluate for lower tract injury
• G9609 – Documentation of an order for anti-platelet agents
• G9610 – Documentation of medical reason(s) in the patient's record for not ordering anti-platelet agents
• G9611 – Order for anti-platelet agents was not documented in the patient's record, reason not given
• G9612 – Photodocumentation of two or more cecal landmarks to establish a complete examination
• G9613 – Documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal resection, etc.)
• G9614 – Photodocumentation of less than two cecal landmarks (i.e., no cecal landmarks or only one cecal landmark) to establish a complete examination
• G9615 – Preoperative assessment documented
• G9617 – Preoperative assessment not documented, reason not given
• G9618 – Documentation of screening for uterine malignancy or those that had an ultrasound and/or endometrial sampling of any kind
• G9619 – Documentation of reason(s) for not screening for uterine malignancy (e.g., prior hysterectomy)
• G9620 – Patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not given
• G9621 – Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling
• G9622 – Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method
• G9623 – Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons)
• G9624 – Patient not screened for unhealthy alcohol use using a systematic screening method or patient did not receive brief counseling if identified as an unhealthy alcohol user