HCPCS code G0294 – Noncovered procedures in a Medicare qualifying clinical trial (no or local anesthesia)

Key takeaways

HCPCS code G0294 reports a noncovered procedure done with no anesthesia or local anesthesia only in a Medicare qualifying clinical trial, once per day.

Use G0293 instead when the noncovered procedure involves conscious sedation or regional, general or spinal anesthesia.

G0294 is not payable under the physician fee schedule. Under the hospital OPPS it carries status indicator Q1, so it is packaged or paid under APC 5732.

Trial claims need the 8-digit NCT number and ICD-10-CM code Z00.6, plus condition code 30 on institutional claims.

Most problems trace back to a missing NCT number, the retired QV modifier, or a G0294 line sent to the physician fee schedule.

What is HCPCS code G0294?

HCPCS code G0294 is the Level II code for a noncovered procedure using no anesthesia or local anesthesia only in a Medicare qualifying clinical trial. It is reported once per day. CMS added it on January 1, 2003, together with its companion code G0293, and both are still active in the October 2026 HCPCS file.

The code tells Medicare that a trial procedure falls outside coverage. That lets the payer separate it from the routine care it does pay for under its clinical trial policy. G0294 has no connection to preventive, counseling or behavioral services.

• Long descriptor: Noncovered procedure(s) using either no anesthesia or local anesthesia only, in a Medicare qualifying clinical trial, per day
• Short descriptor: Non-cov proc, clinical trial
• Code set: HCPCS Level II G codes, in the miscellaneous diagnostic and therapeutic services range (G0127 to G0372)
• Unit: Per day
• Pricing indicator: 00, a service not separately priced by Part B
• Coverage code: D, special coverage instructions apply
• Processing note 0109: Payment is for hospital outpatient only, and the code is not payable under the physician fee schedule
• OPPS status indicator: Q1 (STV-packaged), assigned to APC 5732

These values come from the CMS quarterly HCPCS file for October 2026. The OPPS status comes from Addendum B. Neighboring G codes sit in our index of HCPCS codes.

G0293 vs G0294: Which clinical trial code applies

G0293 and G0294 describe the same situation and differ only in the anesthesia used. Both report a noncovered procedure in a Medicare qualifying clinical trial, and both are billed per day.

A study-only biopsy under local anesthesia goes to G0294. The same biopsy under moderate sedation moves to G0293. Record the anesthesia type in the procedure note, because it is the only detail that decides between the two codes.

How Medicare’s clinical trial policy (NCD 310.1) applies to G0294

National Coverage Determination 310.1, Routine Costs in Clinical Trials, sets what Medicare pays for when a beneficiary takes part in a qualifying trial. It splits trial care into routine costs, which Medicare covers, and items it excludes.

Medicare covers these routine costs:

• Items and services the patient would typically receive outside the trial
• Services needed to provide the investigational item, such as its administration
• Clinically appropriate monitoring of the item’s effects
• Prevention, diagnosis and treatment of complications

Medicare excludes these:

• The investigational item or service itself, unless Medicare covers it outside the trial
• Items and services provided only for data collection and not used in the patient’s direct care
• Items and services the trial sponsor customarily provides free of charge

G0294 sits on the excluded side. A typical example is an extra biopsy taken only for study data, under local anesthesia or none.

The NCD also defines which trials qualify. A trial must study an item in a Medicare benefit category and have therapeutic intent. Trials funded by NIH, CDC, AHRQ, CMS, the Department of Defense or the VA are deemed to qualify. So are trials run under an FDA investigational new drug application, and drug trials exempt from one.

Clinical trial identifiers: NCT number, Z00.6 and condition code 30

Medicare recognizes a trial claim by its identifiers. Each one has a fixed place on the claim, and the place differs between institutional and professional claims.

CMS made the trial number mandatory for dates of service from January 1, 2014. A claim without it is returned as unprocessable, per CMS Transmittal 2955.

Modifiers Q0 and Q1, and the retired QV

Modifiers mark each covered line on a trial claim as investigational or routine. Q1 replaced the older QV modifier on January 1, 2008.

G0294 reports a noncovered procedure, so a routine-care modifier does not describe it. CMS’s original instructions barred QV from noncovered items, and Q1 took over that role. Put Q1 on the covered routine lines, and confirm line-level rules for G0294 with your Medicare Administrative Contractor (MAC).

How Medicare pays or packages G0294

Medicare does not pay G0294 under the physician fee schedule. The code carries pricing indicator 00, which CMS defines as a service that Part B does not price separately. Processing note 0109 adds that payment is for hospital outpatient only.

On a hospital outpatient claim, the OPPS Addendum B lists G0294 with status indicator Q1 in APC 5732. Q1 means STV-packaged. The line is packaged when the claim carries a status S, T or V service, and otherwise paid at the APC rate of $38.16.

Two cautions apply. Appearing in Addendum B does not itself mean the service is covered. And status indicator Q1 has no connection to the Q1 modifier that marks routine trial lines.

Routine trial costs are paid through the lines that carry modifier Q1 under NCD 310.1, or Q0 for a covered investigational item. The trial’s clinical trial agreement usually decides who pays for the noncovered procedure. Read the agreement and the informed consent before you bill the patient for any part of it.

The map below shows where each kind of protocol procedure lands on the claim, with G0294 as one of five outcomes.

Common denial patterns for G0294 claims

G0294 claims usually fail on the trial identifiers around the code. Each pattern below has a fix you can apply before submission, which keeps denial management work to a minimum.

Good medical billing compliance practice treats the coverage analysis as the source document for every one of these checks. A clean claim for a trial patient starts there.

How claims management software keeps clinical trial claims complete

Research billing breaks down when the trial details sit in a binder and the claim sits in a billing system. A biller who cannot see the NCT number or the coverage analysis has to guess, and the payer returns the claim.

Pabau, the practice management and billing platform we build, keeps the patient record and the claim in one place. Its claims management software scrubs each claim for missing or invalid details before it leaves your practice. CMS-1500 claims go out through Claim.MD, and rejected claims come back flagged with the reason.

For a practice that sees trial patients, that gives your team one place to confirm the Q1 lines, Z00.6 and the trial number before submission. A missing identifier gets fixed before the claim goes out, so you avoid waiting on a return to find it.

Send cleaner clinical trial claims

Pabau scrubs every claim for missing details before it leaves your practice and shows the reason behind each rejection. See how it fits your billing workflow.

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Conclusion

Treat G0294 as a coverage flag first and a payment line second. The physician fee schedule pays nothing for it, and on a hospital claim OPPS packages it or pays it under APC 5732. Either way, its job is to keep a study-only procedure off the covered lines.

When a trial claim fails, check the NCT number, Z00.6 and condition code 30 before you question the code itself.

Build the coverage analysis once per trial and code every visit from it. To see how Pabau keeps the patient record and the claim together, book a demo.

Continue your research

Billing the same procedure under sedation? HCPCS code G0293 covers noncovered trial procedures with conscious sedation or regional, general or spinal anesthesia.

Need to understand denial patterns across your HCPCS claims? Denial management in healthcare walks through the root-cause analysis process for common remittance denial codes.

Want to streamline your full Medicare billing workflow? What is revenue cycle management covers the end-to-end process from eligibility verification to payment posting.

Billing research visits and need a compliance framework? Medical billing compliance outlines the documentation and audit standards behind compliant claims.

Working a returned or denied trial claim? Denial codes in medical billing explains the CARC and RARC codes on your remittance.

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