HCPCS Code G8431: Screening for Depression Is Documented as Being Positive and a Follow-Up Plan Is Documented

Learn what you need for successful HCPCS G8431 claims. Read documentation, billing, and modifier usage tips here.

## **What is a screening for depression?** HCPCS Code G8431 is the HCPCS code for screening scenarios where a standardized depression screen is positive and a follow-up plan is documented in the record. The official long name of the code is “Screening for depression is documented as being positive and a follow-up plan is documented.” Screening tools help clinicians quickly identify symptoms, prompt a risk review, and start a referral process or treatment plan. A validated screening tool must be used, and examples include PHQ-2, PHQ-9, the Beck Depression Inventory, the Edinburgh Postnatal Depression Scale for postpartum maternal depression screening, and the Geriatric Depression Scale for older adults. G8431 is reporting-only and is often paired with an E/M visit or CPT 96127 for brief emotional or behavioral assessment. You must record what happens after a positive depression screen, such as same-day counseling, safety planning, medication initiation, referral to behavioral health, or scheduling a warm handoff to an in-house therapist. This constitutes the "follow-up" part. It matters because early identification and timely action reduce complications and connect patients to mental health services without delay. Medical practices can also use this code when an infant's health care provider performs post partum depression screening assessments during well-child visits and the mother screens positive, as long as the chart clearly shows who was screened and how the team will treat mothers who need help.

## **G8431 documentation requirements** Document clearly so the measure counts and the record supports your quality report. ### **Patient eligibility and timing** Note the encounter date and that the patient meets the program’s age criteria. Most programs accept administration on the visit date or within a short look-back window documented in the chart. ### **Validated tool and result** Name the validated screening tool used and capture the score or threshold crossed. Examples include PHQ-2, PHQ-9, EPDS, BDI, or GDS. Explicitly state that this was a positive depression screen. ### **Risk and safety checks** Record suicide risk screening when indicated, any acute risk factors, and immediate steps taken. Include crisis resources given and whether a same-day behavioral health evaluation was offered. ### **Follow-up plan details** Describe the plan in actionable terms: referral to counseling, pharmacotherapy initiation, brief behavioral intervention, or scheduled re-screening with a target date. Make the referral process traceable by listing the destination service and timeframe. ### **Exclusions and exceptions** If program rules exclude patients with active major depression or bipolar disorder from the denominator, document that diagnosis so the measure is classified correctly. Capture patient refusal or medical reasons when screening cannot be completed. ### **Special postpartum use** When used for postpartum maternal depression screening, specify whether a maternal health care provider or an infant's health care provider performed the screen, what tool was used, that the mother screens positive, and how you will treat mothers who need follow-up.

## **G8431 billing requirements** G8431 is reported for quality tracking and typically does not change payment, but claims must line up with the visit. ### **Pair with the primary service** Report G8431 alongside the E/M service or CPT 96127 when the screening occurs. Ensure the date of service matches and the documentation supports both codes. ### **Setting and program** Use G8431 within programs such as MIPS or payer quality initiatives. For Medicaid populations that recognize maternal screening during pediatric visits, follow state instructions for submitting under the infant’s ID when applicable and note postpartum context in the chart. ### **Telehealth encounters** You may report G8431 for telehealth encounters when the screening and follow-up plan occur during a synchronous visit and the note captures tool, score, and plan. Use the payer’s required telehealth indicators. ### **Denominator management** Apply measure exclusions correctly by documenting pre-existing depression or bipolar disorder when the program designates them as denominator exclusions. That keeps your report accurate. ### **Audit-ready records** Keep the full screen, score, follow-up plan, referrals, and any handoff notes so your report can be verified later. Consistency between the clinical note and the claim line is essential.

## **G8431 applicable modifiers** Use modifiers only when a payer requires them for the encounter context. 1. **95**: Synchronous telemedicine service delivered via real-time audio-video when a payer requires telehealth identification. 1. **GT** or **GQ**: Telehealth identifiers still requested by some legacy payers or Medicaid plans; follow current plan rules. 1. **HD**: Used by some Medicaid programs when postpartum maternal depression screening is performed and reported as part of maternal services or during pediatric visits. Most payers do not require modifier 25 solely because you report G8431, since it is a quality measure line that does not represent a separate procedure.

## **Other relevant codes** If today’s visit also needs a code for the screening service or for a different measure state, these related codes are often reported together. - **G8510**: Screening for clinical depression documented as negative; follow-up plan not required. - **G8433**: Screening not completed with a documented reason, such as refusal or emergent condition. - **G8432**, **G8511**: Variations that capture when screening or follow-up documentation is missing or when a rationale is recorded. - **96127**: Brief emotional or behavioral assessment per standardized instrument. Often the paid service line that pairs with this reporting measure.

Frequently asked questions

Yes. You can report G8431 when the screen and follow-up plan occur during a real-time virtual visit and the note includes the validated screening tool, the positive result, and the plan. Add the telehealth modifier your payer requires and ensure the platform and documentation meet policy standards.

Any actionable, documented plan qualifies. That can be a referral to behavioral health, in-clinic counseling with a licensed professional, medication initiation with monitoring, or a scheduled safety check with specific return precautions. The key is a clear plan with timing and accountability.

Frequency depends on payer policy and program design. Many plans allow reporting at multiple well-child visits in the early months when post partum depression screening assessments are recommended, but the code is typically reported once per date of service. Follow your state Medicaid or plan rules if the screen is billed under the infant’s record and make sure documentation shows the mother screens positive and a follow-up plan is in place.