M1158 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1158: History of Immunocompromising Conditions

HCPCS Level II code M1158 denotes that a patient had a history of immunocompromising conditions prior to or during the measurement period. This marker is used in clinical documentation and quality measurement to identify patients for whom standard preventive and therapeutic approaches may require adjustment. Nationally, consistent capture of immunocompromised status affects population health analytics, vaccine- and infection-related quality metrics, and risk stratification for care management programs.

Key payers covered in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on the clinical meaning of M1158, typical service settings where the code is recorded, and how the code interfaces with measurement and reporting workflows. The publication summarizes benchmarking considerations, common documentation workflows, and policy-relevant implications for payers and providers regarding quality measurement and care stratification.

This national-level summary is intended to inform coding, documentation, and quality-measure processes by clarifying the role of M1158 in identifying patients with immunocompromising histories. Data not available in the input will be noted where relevant in detailed sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1158HCPCS Level IIimmunocompromisedquality measurementoutpatientdocumentationcare managementpreventive care

Billing Code Overview

HCPCS Level II code M1158 indicates that a patient had a history of immunocompromising conditions prior to or during the measurement period. This designation is used to identify patients whose immune status may affect clinical decision-making, preventive care measures, and quality measurement calculations.

Service type: Assessment/documentation of immunocompromising history for care planning and quality measurement
Typical site of service: Ambulatory care settings, primary care clinics, specialty clinics (including infectious disease, oncology, and transplant follow-up), and other outpatient care locations

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with an active or prior immunocompromising condition—such as solid organ transplant, hematologic malignancy, HIV with low CD4 count, receipt of systemic chemotherapy, or chronic high‑dose corticosteroid therapy—who presents for routine preventive care or an acute visit during the measurement period. The clinical workflow begins with the clinician documenting the patient’s immunocompromised history in the medical record during intake or medication review. This prompts care-team actions such as evaluation for infection risk, counseling about live vaccines and prophylactic therapies, ordering of relevant laboratory tests (e.g., CD4 count, complete blood count), and coordination with specialty providers (oncology, transplant, infectious disease). Billing staff assign the HCPCS Level II code M1158 to indicate the patient had a history of immunocompromising conditions prior to or during the measurement period, supporting quality measurement, risk stratification, and appropriate care planning. Typical sites of service include primary care clinics, specialty outpatient clinics (hematology/oncology, transplant, infectious disease), community health centers, and hospital ambulatory care clinics. Usual patient scenarios include: a transplant recipient returning for surveillance; a patient on chronic immunosuppressive therapy seen for vaccine planning; or a cancer survivor receiving follow‑up with documented prior immunosuppression.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS M1304: Adult Pneumococcal Vaccination Status Not Received

HCPCS-M1167-HOSPICE-ENROLLMENT-OR-HOSPICE-SERVICE-USE

HCPCS M1167: In Hospice or Using Hospice Services During Measurement Period

HCPCS-M1424-PULMONOLOGY-MIPS-VALUE-PATHWAY

HCPCS M1424: Pulmonology Care MIPS Value Pathway

HCPCS-M1189-KIDNEY-HEALTH-EVALUATION-EGFR-UACR

HCPCS M1189: Kidney Health Evaluation with eGFR and UACR

HCPCS-M1207-SOCIAL-NEEDS-SCREENING-FOOD-HOUSING-TRANSPORTATION-SAFETY

HCPCS M1207: Social Needs Screening for Food, Housing, Transportation, Safety

HCPCS-M1413-PD-L1-POSITIVE-PRE-FIRST-LINE-IMMUNOTHERAPY

HCPCS M1413: PD-L1 Positive Prior to First-Line Immune Checkpoint Inhibitor Therapy

HCPCS-M1267-KIDNEY-TRANSPLANT-WAITLIST-INACTIVE-STATUS

HCPCS Level II M1267: Kidney/Kidney-Pancreas Transplant Waitlist Inactive Status

HCPCS-M1153-OSTEOPOROSIS-DIAGNOSIS-ENCOUNTER

HCPCS M1153: Patient with Osteoporosis on Date of Encounter

HCPCS-M1205-ITCH-SEVERITY-IMPROVEMENT-ASSESSMENT

HCPCS M1205: Itch Severity Improvement Assessment

HCPCS-M1174-HERPES-ZOSTER-RECOMBINANT-VACCINE-SERIES-COMPLETION

HCPCS M1174: Herpes Zoster Recombinant Vaccine Series Completion

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Taxonomy Code	Specialty	Notes
207Q00000X	Infectious Disease	Manages complex infection risk, vaccine decisions, and prophylaxis in immunocompromised patients.
207L00000X	Hematology & Oncology	Manages chemotherapy-related immunosuppression and follow‑up care.
207P00000X	Transplant Surgery	Manages solid‑organ transplant recipients and long‑term immunosuppression monitoring.
207R00000X	Allergy & Immunology	Evaluates primary immunodeficiencies and immunomodulatory therapy implications.
208D00000X	Family Medicine	Provides primary care, documentation of immunocompromising conditions, and routine preventive care coordination.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z94.0`	Kidney transplant status	Indicates prior organ transplant and ongoing immunosuppression risk relevant to `M1158`.
`Z94.1`	Heart transplant status	Identifies heart transplant recipients with chronic immunosuppressive therapy.
`C91.00`	Acute lymphoblastic leukemia not having achieved remission	Reflects hematologic malignancy with treatment-related immunosuppression.
`D84.9`	Immunodeficiency, unspecified	Represents primary or secondary immunodeficiency warranting documentation.
`B20`	Human immunodeficiency virus [HIV] disease	Indicates HIV infection, with potential immunocompromise influencing care planning.
`Z79.899`	Other long term (current) drug therapy	Used to denote chronic immunosuppressive medication therapy as part of the immunocompromised history.
`T45.1X5A`	Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter	Captures drug‑related immunosuppression events relevant to the patient’s history.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	May be performed during a visit where immunocompromised status is documented and counseling provided on risk mitigation.
`99396`	Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; 40-64 years	Used during preventive visits where the immunocompromised history `M1158` is documented to guide preventive care and vaccine planning.
`99401`	Preventive medicine counseling, individual, approximately 15 minutes	Used when focused counseling about infection prevention or vaccination in an immunocompromised patient is delivered.
`36415`	Collection of venous blood by venipuncture	Commonly performed for laboratory monitoring (CBC, CD4 count, drug levels) associated with managing immunocompromised patients.
`86580`	Skin test for tuberculosis, intradermal (e.g., Mantoux test), with interpretation and report	Often performed prior to initiating certain immunosuppressive therapies or vaccines in immunocompromised patients.

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