A G Code is a type of Healthcare Common Procedure Coding System (HCPCS) Level II code used by Medicare and other payers to identify specific professional services or procedures (including devices and practice expenses) not covered by the American Medical Association’s Current Procedural Terminology (CPT) codes. G Codes are assigned by the Centers for Medicare & Medicaid Services (CMS) to support new procedures (including devices and practice expenses) or to address gaps in CPT code coverage.

• Short Answer: G Codes exist to cover services or procedures (including devices and practice expenses) that are not yet captured by the CPT system.
• Long Answer: New CPT codes are issued by the American Medical Association (AMA) for new Procedures that do not have an applicable CPT code. CPT Code 69433 described a tympanostomy procedure with local or topical anesthetic, therefore, the Hummingbird did not require a new CPT code. However, given the existing CPT Code did not contain adequate practice expenses or the cost of tympanostomy tube delivery systems, CMS determined that an Add-on G Code was the most appropriate way to identify these expenses. CMS uses G Codes as a solution to promptly address coding needs, especially for innovative procedures, pilot programs, or services/supplies not contained in a CPT code.

Providers are required to use the add-on G Code +G0561 with the primary tympanostomy procedure CPT code 69433 when using the Hummingbird TTS in the physician’s office.  Doing so aligns with proper coding guidelines for accurately reporting the costs associated with specific procedures, especially when additional resources are required, as with pediatric tympanostomy procedures in an office setting.

Proper Coding Guidelines for Using Add-on G Code (e.g., +G0561):

• Pairing with Primary Code: The G Code (e.g., +G0561) is designed as an add-on code and should be billed in conjunction with the primary tympanostomy CPT code 69433. The G Code is not intended to stand alone; it enhances the base code by capturing the added practice expenses involved in performing the procedure in-office.
• Documentation Requirements: Providers should include thorough documentation when billing with an add-on G Code. This includes specifics on the additional equipment (such as the Hummingbird device) and additional staff resources required to manage the procedure effectively in an office environment.
• Reimbursement Implications: Using the G Code accurately reflects the increased costs associated with pediatric cases, helping to ensure more appropriate reimbursement. Not using it may result in under compensation for in-office tympanostomy on pediatric patients where specialized tools and support staff are essential.

By adhering to these coding guidelines, providers ensure they are compliant and transparent about the resources used for pediatric tympanostomy procedures, improving the likelihood of correct and complete reimbursement.

Not all G Codes have an assigned national payment rate. Some are “contractor-priced,” meaning their value is determined by Medicare Administrative Contractors (MACs), commercial payers, or Medicaid plans rather than by a national CMS-set value. +G0561 is currently a contractor priced add-on Code.

For contractor-priced G Codes, reimbursement rates may vary by region and payer, with MACs and payers setting valuations based on specific local criteria, costs, and utilization data.

When a G Code is designated as contractor-priced, Medicare Administrative Contractors (MACs), commercial payers, and Medicaid plans individually determine the reimbursement rate. This approach results in a decentralized pricing system where reimbursement rates for contractor-priced G Codes can vary by region. Payers will consider local practice costs, patient demographics, and additional procedure-specific resources required, which means that providers may experience different payment levels based on their location. Providers need to understand the regional pricing by coordinating with MACs, commercial payers, and state Medicaid programs to determine reimbursement for specific G-Code procedures. Providers may have to collaborate with their provider relations representatives at commercial payers to negotiate a payment rate for the code.

The code went live on 1/1/2025, however, given the code is new, it is not yet covered by all State Medicaid plans. The Hummingbird Reimbursement Support team can provide additional information on state-specific policies.

In certain instances, Providers may bill Medicaid patients for non-covered services or items if the patient’s Medicaid plan does not yet cover or pay for +G0561. However, state laws may limit beneficiary liability, and each state has different policies and requirements. Please refer to state-specific policies and specific Medicaid Payer agreements for guidance.