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)
G9616 is a HCPCS Level II code for 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). It belongs to the Procedures and Professional Services (Temporary) section. It was terminated on December 31, 2020 and is not valid on new claims.
This code has been terminated
CMS terminated G9616 on December 31, 2020. It stays in the file as history — a claim you are auditing from before that date may legitimately carry it — but it must not appear on a new claim. The adjacent codes below are the usual place to look for its replacement.
Medicare coverage: Carrier judgment
Coverage is decided by your Medicare contractor, not by national policy. Whether this is paid depends on the LCD for your jurisdiction and on what the documentation supports.
From the coverage field of the CMS Alpha-Numeric HCPCS File, release 2026Q3-Jul. This states Medicare’s position on the code, not on your particular claim.
The CMS record for G9616
- Long descriptor
- 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 descriptor
- Doc rsn no preop assmt
- Added
- January 1, 2016
- Terminated
- December 31, 2020
- BETOS
- Z2
- Pricing indicator
- 00 — Not priced by Part B
The official wording. This is what the code means.
CMS's 28-character form, which is what shows up on a remittance advice.
When CMS introduced the code.
When CMS retired it.
Berenson-Eggers Type of Service — CMS's own analytic grouping.
Service not separately priced by Part B — not covered, bundled into another service, or used by Part A only.
Codes adjacent to G9616
HCPCS has no hierarchy — related items simply sit next to each other in the numbering. If G9616 is not quite right, the correct code is very often within a few positions of it.
- G9608Intraoperative cystoscopy not performed to evaluate for lower tract injury
- G9609Documentation of an order for anti-platelet agents
- G9610Documentation of medical reason(s) in the patient's record for not ordering anti-platelet agents
- G9611Order for anti-platelet agents was not documented in the patient's record, reason not given
- G9612Photodocumentation of two or more cecal landmarks to establish a complete examinationterminated
- G9613Documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal resection, etc.)terminated
- G9614Photodocumentation of less than two cecal landmarks (i.e., no cecal landmarks or only one cecal landmark) to establish a complete examinationterminated
- G9615Preoperative assessment documentedterminated
- G9617Preoperative assessment not documented, reason not giventerminated
- G9618Documentation of screening for uterine malignancy or those that had an ultrasound and/or endometrial sampling of any kindterminated
- G9619Documentation of reason(s) for not screening for uterine malignancy (e.g., prior hysterectomy)terminated
- G9620Patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not giventerminated
- G9621Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling
- G9622Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method
- G9623Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons)terminated
- G9624Patient 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
Questions about G9616
What is HCPCS code G9616?
G9616 is a HCPCS Level II code for 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). It sits in the Procedures and Professional Services (Temporary) section.
Does Medicare cover G9616?
The CMS HCPCS file marks G9616 as "Carrier judgment". Coverage is decided by your Medicare contractor, not by national policy. Whether this is paid depends on the LCD for your jurisdiction and on what the documentation supports.
Is G9616 still valid?
No. G9616 was terminated on December 31, 2020 and should not be used on new claims.