G8509 - Pain assessment was positive but no follow-up plan was documented

Healthcare Common Procedure Coding System

Last updated: 11/28/2025

What is a HCPCS Code?

HCPCS (Healthcare Common Procedure Coding System) codes are used to identify medical procedures, supplies, and services for billing purposes. These codes help standardize how healthcare services are reported and billed across different providers and insurance companies.

Detailed Description

This code indicates that a healthcare provider conducted a pain assessment using a standardized pain measurement tool (such as a pain scale from 0-10), and the results showed that you were experiencing pain. However, the medical record shows that no follow-up plan was documented to address the identified pain, and no reason was given for why a follow-up plan wasn't created. This code is used for quality reporting purposes to track whether appropriate pain management protocols are being followed.

Additional Information

This is a reporting code used to track quality metrics related to pain management documentation, not a billable service code. It identifies a gap in documentation when pain is detected but no follow-up plan is recorded.

Category

Quality Reporting/Performance Measurement

Medical Specialty

Any specialty that performs pain assessments

Expected Costs

Your actual cost will depend on your insurance coverage, provider location, and specific circumstances.

What's Required Before This

  • Prior pain assessment using standardized tool
  • Positive pain assessment results

What to Expect After

  • May require documentation of pain management plan
  • Potential need for pain reassessment

Why Understanding This Code Matters

On Your Medical Bill

This code appears on your medical bills to identify the specific service, procedure, drug, or medical diagnosis you received. Understanding what it means helps you verify you're being charged correctly and know what to expect.

For Your Health

Knowing what this code represents helps you understand your treatment plan, ask better questions during appointments, and track your healthcare journey more effectively.

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