Key facts for G0397
- Medicare payment
- $67.47
- PFS non-facility, national; facility $55.11
- Coverage code
- C
- carrier judgment, so the Medicare contractor decides coverage
- Practitioner MUE
- 1
- MAI 2
- NCCI PTP pairs
- 115
- 112 hospital outpatient
- LCDs and articles
- 0 / 0
- on the Medicare telehealth list
TL;DR
HCPCS Level II G0397 reads "Alcohol and/or substance (other than tobacco) misuse structured assessment (e.g., audit, dast), and intervention, greater than 30 minutes" in the October 2026 file; it dates from 2008. National PFS payment for G0397 is $67.47 in an office and $55.11 in a facility (October 2026), built from 1.30 work, 0.65 practice-expense and 0.07 malpractice RVUs at $33.4009 per RVU. Qualifying APM participants get $67.81 at $33.5675. CMS caps G0397 at practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction) units per day in the 2026 Q4 MUE tables. In the NCCI PTP files v323r0 G0397 appears in 101 practitioner pairs as column 2 and 14 as column 1 (most often with 90791, 90792, 90832), and in 100 hospital outpatient pairs as column 2 and 12 as column 1. No current LCD or billing article lists G0397; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage). It is on the CY2026 Medicare telehealth list (CMS action: Maintain). HCPCS record: BETOS M5D (specialist - other); pricing indicator 11; type of service 1 (medical care). 2 other active codes open with "Alcohol and/or substance"; related codes: G0396, G2011, G0398, G0399.
G0397 descriptor and code status
The October 2026 HCPCS Level II file describes G0397 as “Alcohol and/or substance (other than tobacco) misuse structured assessment (e.g., audit, dast), and intervention, greater than 30 minutes”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes.
| Field | Value |
|---|---|
| Short descriptor | Alcohol/subs interv >30 min |
| Added to HCPCS | 2008-01-01 |
| Last action | N (no maintenance), effective 2020-10-01 |
| Coverage code | C: carrier judgment, so the Medicare contractor decides coverage |
| Pricing indicator | 11: physician fee schedule, priced with national RVUs |
| BETOS category | M5D: specialist - other |
| Type of service | 1: medical care |
Medicare payment for G0397
National PFS payment for G0397 is $67.47 in an office and $55.11 in a facility (October 2026), built from 1.30 work, 0.65 practice-expense and 0.07 malpractice RVUs at $33.4009 per RVU. Qualifying APM participants get $67.81 at $33.5675. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.
Physician fee schedule (RVU26D)
Status A: active: paid separately under the physician fee schedule when covered. Global period XXX (global surgery concept does not apply); PC/TC indicator 0 (physician service; the professional/technical split does not apply).
| Component | Non-facility | Facility |
|---|---|---|
| Work RVU | 1.30 | 1.30 |
| Practice expense RVU | 0.65 | 0.28 |
| Malpractice RVU | 0.07 | 0.07 |
| Total RVUs | 2.02 | 1.65 |
| National payment (CF $33.4009) | $67.47 | $55.11 |
| Qualifying APM participant (CF $33.5675) | $67.81 | $55.39 |
- Multiple procedures (modifier 51): no multiple-procedure reduction
- Bilateral (modifier 50): 150% bilateral adjustment does not apply
- Assistant at surgery: assistant at surgery paid only with documentation; co-surgeons: co-surgeons not permitted; team surgery: team surgeons not permitted
- Physician supervision of diagnostic procedures: supervision concept does not apply
Hospital outpatient (OPPS Addendum B)
Status indicator S (Procedure or service, not discounted when multiple), APC 5823 (Level 3 Health and Behavior Services), national unadjusted payment $181.34 with a minimum unadjusted copayment of $36.27.
Medically Unlikely Edits for G0397
CMS caps G0397 at practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction) units per day in the 2026 Q4 MUE tables. The practitioner MUE is a date-of-service policy edit: units above the limit deny even when split across lines, and appeals rarely succeed.
| Setting | MUE (units/DOS) | MAI | CMS rationale |
|---|---|---|---|
| Practitioner services | 1 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
| Facility outpatient hospital | 1 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
The MUE lookup for G0397 shows every setting next to any other code on the same claim.
NCCI edits and add-on rules
In the practitioner PTP file v323r0, G0397 is the column-2 (bundled) code in 101 active pairs, 94% of which allow a modifier and the column-1 code in 14 (14% modifier-allowed); 194 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Standards of medical/surgical practice.
| Column-1 code | Pairs |
|---|---|
| 90791 (CPT; descriptor licensed by AMA) | 1 |
| 90792 (CPT; descriptor licensed by AMA) | 1 |
| 90832 (CPT; descriptor licensed by AMA) | 1 |
| 90833 (CPT; descriptor licensed by AMA) | 1 |
| 90834 (CPT; descriptor licensed by AMA) | 1 |
| 90836 (CPT; descriptor licensed by AMA) | 1 |
| 90837 (CPT; descriptor licensed by AMA) | 1 |
| 90838 (CPT; descriptor licensed by AMA) | 1 |
| Column-2 code | Pairs |
|---|---|
| 36591 (CPT; descriptor licensed by AMA) | 1 |
| 36592 (CPT; descriptor licensed by AMA) | 1 |
| 96159 (CPT; descriptor licensed by AMA) | 1 |
| 96160 (CPT; descriptor licensed by AMA) | 1 |
| 96161 (CPT; descriptor licensed by AMA) | 1 |
| 96164 (CPT; descriptor licensed by AMA) | 1 |
| 96165 (CPT; descriptor licensed by AMA) | 1 |
| 96168 (CPT; descriptor licensed by AMA) | 1 |
In the hospital outpatient PTP file v323r0, G0397 is the column-2 (bundled) code in 100 active pairs, 97% of which allow a modifier and the column-1 code in 12 (58% modifier-allowed); 192 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Standards of medical/surgical practice.
| Column-1 code | Pairs |
|---|---|
| 90791 (CPT; descriptor licensed by AMA) | 1 |
| 90792 (CPT; descriptor licensed by AMA) | 1 |
| 90832 (CPT; descriptor licensed by AMA) | 1 |
| 90833 (CPT; descriptor licensed by AMA) | 1 |
| 90834 (CPT; descriptor licensed by AMA) | 1 |
| 90836 (CPT; descriptor licensed by AMA) | 1 |
| 90837 (CPT; descriptor licensed by AMA) | 1 |
| 90838 (CPT; descriptor licensed by AMA) | 1 |
| Column-2 code | Pairs |
|---|---|
| 96159 (CPT; descriptor licensed by AMA) | 1 |
| 96160 (CPT; descriptor licensed by AMA) | 1 |
| 96161 (CPT; descriptor licensed by AMA) | 1 |
| 96164 (CPT; descriptor licensed by AMA) | 1 |
| 96165 (CPT; descriptor licensed by AMA) | 1 |
| 96167 (CPT; descriptor licensed by AMA) | 1 |
| 96168 (CPT; descriptor licensed by AMA) | 1 |
| 99408 (CPT; descriptor licensed by AMA) | 1 |
G0397 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.
Pair counts show exposure, not the answer for one claim. Check G0397 against a second code to see whether the pair bundles and whether a modifier can separate the services.
Medicare coverage policies for G0397
No current LCD or billing and coding article lists G0397. The HCPCS coverage code C means carrier judgment, so the Medicare contractor decides coverage, and any National Coverage Determination for the service still applies.
Telehealth status
G0397 is on the CY2026 Medicare telehealth services list (CMS action: Maintain). Bill it with the place-of-service code and modifiers that match where the patient and the practitioner are on the date of service.
Denials to expect on G0397
the modifier reported is inconsistent with the code
the claim lacks information needed to adjudicate the line, such as an order, NPI or required modifier
Where QuickIntell fits for G0397 claims
QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0397 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.
Frequently asked questions: HCPCS G0397
What does HCPCS code G0397 describe?
"Alcohol and/or substance (other than tobacco) misuse structured assessment (e.g., audit, dast), and intervention, greater than 30 minutes" (short descriptor "Alcohol/subs interv >30 min"), in the G section (procedures and professional services, temporary). Added 2008-01-01; last action N (no maintenance) effective 2020-10-01.
Is G0397 a CPT code?
It is not. G0397 belongs to the G section (procedures and professional services, temporary) of HCPCS Level II, the CMS code set, not to AMA CPT.
What does Medicare pay for G0397?
National PFS payment for G0397 is $67.47 in an office and $55.11 in a facility (October 2026), built from 1.30 work, 0.65 practice-expense and 0.07 malpractice RVUs at $33.4009 per RVU. Qualifying APM participants get $67.81 at $33.5675.
How many units of G0397 can be billed per day?
CMS caps G0397 at practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction) units per day in the 2026 Q4 MUE tables. For the practitioner MUE (MAI 2), units above 1 deny for the whole day as a policy limit; denials arrive as CARC 151.
Does Medicare cover G0397?
No current LCD or billing article lists G0397; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage).
Can G0397 be billed as telehealth?
Yes. G0397 is on the CY2026 Medicare telehealth list (Maintain); the place-of-service and modifier rules on the date of service still apply.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- HCPCS Level II alpha-numeric file, October 2026Version October 2026 · effective 2026-10-01 · file HCPC2026_OCT_ANWEB_09232026.txtSHA-256 c25240c63108756d…
- Medicare PFS national relative value file RVU26D (non-QPP), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_nonQPP.csvSHA-256 4d0d3f19bd954ffc…
- Medicare PFS national relative value file RVU26D (qualifying APM participants), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_QPP.csvSHA-256 59d3734704853936…
- OPPS Addendum B, October 2026Version October 2026 · effective 2026-10-01 · file 508-compliant-version-2026_October_Web_Addendum_B.09.28.26.csvSHA-256 6ad7393a318bf1b9…
- Integrated Outpatient Code Editor v27.3 data tables: status and payment indicatorsVersion I/OCE v27.3 (October 2026) · effective 2026-10-01 · file Data_Status_Indicator.txtSHA-256 78f119ef0a435351…
- NCCI MUE table, practitioner services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_PractitionerServices_Eff_10-01-2026.csvSHA-256 ef038efaf902b7bd…
- NCCI MUE table, facility services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_OutpatientHospitalServices_Eff_10-01-2026.csvSHA-256 3af9f4e99cc587e2…
- NCCI MUE table, dme services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_DMESupplierServices_Eff_10-01-2026.csvSHA-256 6fa4fbba852f7b74…
- NCCI PTP edits, practitioner, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccipra-v323r0-f1.TXTSHA-256 7793c0b6686c1e22…
- NCCI PTP edits, hospital outpatient, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccioph-v323r0-f1.txtSHA-256 063f41b91ef9faa2…
- List of Medicare telehealth services, calendar year 2026Version CY2026 PFS final rule list · effective 2026-01-01 · file CY 2026 PFS Final List of Medicare Telehealth Services.xlsxSHA-256 37a2639174aab141…
Disclaimer
This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.