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HCPCS G0469 · Level II · G code

G0469: Federally qualified health center (FQHC) visit, mental health, new patient, HCPCS Level II G code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: HCPCS Level II file: October 2026 (effective October 1, 2026); PFS relative value file: RVU26D, released August 26, 2026 (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); OPPS Addendum B: October 2026 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update) for the HCPCS Level II file and NCCI MUE tables and NCCI PTP edits and OPPS Addendum B; RVU27A with the CY2027 PFS final rule, effective January 1, 2027 for the PFS relative value file.

Key facts for G0469

Medicare payment
no PFS amount
PFS status X; OPPS SI A: paid under another fee schedule or system
Coverage code
C
carrier judgment, so the Medicare contractor decides coverage
Practitioner MUE
1
MAI 2
OPPS status
SI A
Services not paid under OPPS; paid under fee schedule or other payment system
NCCI PTP pairs
3
practitioner file
LCDs and articles
0 / 0

TL;DR

HCPCS Level II G0469 reads "Federally qualified health center (fqhc) visit, mental health, new patient; a medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a mental health visit" in the October 2026 file; it dates from 2014. The physician fee schedule lists G0469 with status X (statutory exclusion: not a physician service under the fee schedule), so the PFS carries no national amount for it. Its OPPS status indicator is A, which the I/OCE table defines as "Services not paid under OPPS; paid under fee schedule or other payment system": Medicare pays G0469 under a fee schedule or payment system other than OPPS. CMS caps G0469 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 G0469 appears in 0 practitioner pairs as column 2 and 3 as column 1. No current LCD or billing article lists G0469; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage). HCPCS record: BETOS M1A (office visits - new); pricing indicator 13; type of service 1 (medical care). 4 other active codes open with "Federally qualified health center"; related codes: G0468, G0467, G0466, G0470.

G0469 descriptor and code status

The October 2026 HCPCS Level II file describes G0469 as “Federally qualified health center (fqhc) visit, mental health, new patient; a medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a mental health visit”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes.

HCPCS file attributes of G0469
FieldValue
Short descriptorFqhc visit, mh new pt
Added to HCPCS2014-10-01
Last actionN (no maintenance), effective 2014-10-01
Coverage codeC: carrier judgment, so the Medicare contractor decides coverage
Pricing indicator13: physician fee schedule, priced by the contractor
BETOS categoryM1A: office visits - new
Type of service1: medical care

Medicare payment for G0469

The physician fee schedule lists G0469 with status X (statutory exclusion: not a physician service under the fee schedule), so the PFS carries no national amount for it. Its OPPS status indicator is A, which the I/OCE table defines as "Services not paid under OPPS; paid under fee schedule or other payment system": Medicare pays G0469 under a fee schedule or payment system other than OPPS. 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 X: statutory exclusion: not a physician service under the fee schedule. Global period XXX (global surgery concept does not apply); PC/TC indicator 9 (professional/technical concept does not apply).

Hospital outpatient (OPPS Addendum B)

Status indicator A (Services not paid under OPPS; paid under fee schedule or other payment system), with no separate OPPS payment rate.

Medically Unlikely Edits for G0469

CMS caps G0469 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.

MUE values for G0469 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction
Facility outpatient hospital12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction

The MUE lookup for G0469 shows every setting next to any other code on the same claim.

NCCI edits and add-on rules

In the practitioner PTP file v323r0, G0469 is the column-2 (bundled) code in 0 active pairs and the column-1 code in 3 (0% modifier-allowed); 0 earlier pairs have been deleted.

Column-2 codes bundled into G0469 (practitioner)
Column-2 codePairs
36591 (CPT; descriptor licensed by AMA)1
36592 (CPT; descriptor licensed by AMA)1
96523 (CPT; descriptor licensed by AMA)1

G0469 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 G0469 against a second code to see whether the pair bundles and whether a modifier can separate the services.

Medicare coverage policies for G0469

No current LCD or billing and coding article lists G0469. The HCPCS coverage code C means carrier judgment, so the Medicare contractor decides coverage, and any National Coverage Determination for the service still applies.

Denials to expect on G0469

CARC 50 · N115

the service is not reasonable and necessary for the diagnosis on the claim

CARC 151 · N362

units of G0469 exceed the practitioner MUE of 1 per date of service

CARC 4

the modifier reported is inconsistent with the code

CARC 16

the claim lacks the description, invoice or pricing detail a contractor-priced code needs

Where QuickIntell fits for G0469 claims

QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0469 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.

See QuickCode for coder reviewSee QuickRCM for denial follow-upBook a meeting

Frequently asked questions: HCPCS G0469

What does HCPCS code G0469 describe?

"Federally qualified health center (fqhc) visit, mental health, new patient; a medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a mental health visit" (short descriptor "Fqhc visit, mh new pt"), in the G section (procedures and professional services, temporary). Added 2014-10-01.

Is G0469 a CPT code?

It is not. G0469 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 G0469?

The physician fee schedule lists G0469 with status X (statutory exclusion: not a physician service under the fee schedule), so the PFS carries no national amount for it. Its OPPS status indicator is A, which the I/OCE table defines as "Services not paid under OPPS; paid under fee schedule or other payment system": Medicare pays G0469 under a fee schedule or payment system other than OPPS.

How many units of G0469 can be billed per day?

CMS caps G0469 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 G0469?

No current LCD or billing article lists G0469; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage).

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.

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.