Summary & Overview
HCPCS M1004: Documentation of Medical Reason for Not Screening for TB
HCPCS Level II code M1004 captures documentation of a medical reason for not conducting or interpreting a tuberculosis (TB) screening. The code is used when providers record that screening is clinically unnecessary—for example, when a patient has a documented positive TB status or has recently completed anti-TB therapy. Nationally, clear documentation of medical necessity for omitted preventive services affects quality reporting, public health tracking, and payer adjudication.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical context and typical use cases, expectations for where the service is performed, and what documentation elements are generally relevant for claims supporting omission of TB screening or interpretation. The publication also outlines common modifiers associated with HCPCS reporting (listed in the input), and indicates where data elements are not available in the provided input.
This summary addresses why precise use of M1004 matters for billing accuracy and programmatic reporting, clarifies the ambulatory settings where the code is most applicable, and identifies the primary payers covered in the analysis. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code M1004 documents the medical reason for not performing a tuberculosis (TB) screening or for not interpreting TB screening results. Typical clinical scenarios include a patient with a documented history of active TB and completed treatment, or a patient currently positive for TB where repeat screening or interpretation is clinically unnecessary.
Service type: Documentation / Clinical Justification for Omitted TB Screening or Interpretation
Typical site of service: Outpatient clinics, primary care offices, public health clinics, and other ambulatory care settings
Data not available in the input for associated taxonomies, ICD-10 diagnoses, related codes, and service line.
Clinical & Coding Specifications
Clinical Context
A primary care clinician documents a patient encounter where tuberculosis (TB) screening is not performed because the patient has a documented prior active TB diagnosis and completed treatment. The patient is a 45-year-old immigrant with a history of active pulmonary TB treated and declared cured two years prior. At a routine visit for employment clearance, the clinician reviews prior medical records and chest imaging, confirms completed anti-tuberculosis therapy, and records the medical rationale for not performing current TB skin testing or interferon-gamma release assay (IGRA). The workflow includes: chart review for prior positive TB tests or treatment, verification of treatment completion dates, assessment for current symptoms, documentation of the medical reason for not screening using billing code M1004, discussion with the patient about TB history and residual infection risk, and placement of that documentation in the problem list and visit note. Typical sites of service include outpatient primary care clinics, occupational health clinics, and public health departments where documentation of prior treatment or positive status obviates repeat screening.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when documentation supports significantly greater work than typical for documenting medical reasons for not screening for TB. |