## **What is HCPCS code S9986?**
HCPCS code S9986 denotes a non-covered, non‑medically necessary service performed with patient awareness, usually under commercial payer guidelines or self-pay situations.
When an elective or experimental test or service is requested by a patient and the clinician documents that it is not medically indicated, S9986 may be used in claims to indicate that the patient was informed and consented to pay.
This code helps differentiate between denied claims for lack of medical necessity and elective patient-requested services, reducing confusion in medical carrier and payer processing. It is used only in the context where the patient has agreed to proceed despite non-coverage. S9986 is not recognized by Medicare Part B but may be accepted in commercial claim adjudication systems that allow patient-pay codes.
## **HCPCS code S9986 documentation requirements**
Key documentation requirements include:
- The patient must be informed that the service (not medically necessary) and that they are responsible for payment regardless of insurance coverage.
- It is recommended to have a signed Advanced Beneficiary Notice of Noncoverage or equivalent to document that the patient understands the financial implications.
- The documentation or the patient's statement should describe the specific test or service performed.
- This code is often used for screening services where medical necessity is not met. The screening test should be clearly separated from diagnostic tests that meet medical necessity to avoid confusion in billing.
- Testing under this code is ideally done before the patient sees the physician to prevent the assumption that the test was medically required.
- When filing claims, use ICD-10 codes indicating a screening or non-medically necessary service, e.g., Z13.5 for eye and ear disorder screening.
## **HCPCS code S9986 billing requirements**
HCPCS code S9986 billing requirements include:
- The patient must be informed and agree that the service is not covered by insurance and they will pay out-of-pocket. This communication should ideally happen before the service is performed.
- Typically, no claim is filed with insurance since the service is noncovered. Instead, the patient pays directly.
- Pair the billing codes with ICD-10 codes indicating screening or non-medical necessity such as Z13.5 (screening for eye and ear disorders) or general vision screening codes to reflect the service’s nature.
- Maintain documentation showing patient acknowledgment of financial responsibility, clear description of the service as screening or non-medically necessary, and communication to avoid implied medical necessity.
## **Other relevant codes**
- **S9982, S9988** — Also represent non-covered or not medically necessary services
- **A9270** — Non-covered item or service
- **G9918** — Functional status not performed for unspecified reasons
- **T2025** — Waiver services not otherwise specified
- **G9730** — Patient refused to participate
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