Summary & Overview
HCPCS M1160: Anaphylaxis from Meningococcal Vaccine Before Age 13
HCPCS Level II code M1160 documents a history of anaphylaxis attributable to the meningococcal vaccine occurring at any time on or before a patient's 13th birthday. Nationally, accurate capture of vaccine-related anaphylaxis is important for immunization safety monitoring, clinical decision-making about future vaccinations, and administrative recordkeeping that can affect coverage determinations and care pathways.
Key payers in the national landscape include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for using M1160, common billing environments where the code is reported (outpatient pediatrics, allergy clinics, immunization sites), and the practical implications for claims processing and patient records. The publication outlines benchmarks and coding guidance where available, notes limitations in the input data, and summarizes policy and documentation considerations relevant to payers and provider billing teams.
This summary is written for a national audience and focuses on the clinical and administrative significance of M1160 rather than state-specific rules or provider recommendations. Data not available in the input is identified and not inferred.
Billing Code Overview
HCPCS Level II code M1160 indicates that the patient had anaphylaxis due to the meningococcal vaccine any time on or before the patient's 13th birthday. This code documents a serious allergic reaction linked to meningococcal vaccination in a pediatric patient and is used to capture clinical history relevant to immunization safety and future vaccine decision-making.
Service type: Allergy/Immunization-related diagnostic history
Typical site of service: Outpatient clinic or immunization clinic, including pediatrician offices, allergy clinics, and public health vaccination sites.
Clinical & Coding Specifications
Clinical Context
A 12-year-old patient presents to the emergency department within minutes of receiving a routine meningococcal vaccine at a community health clinic. The patient develops acute symptoms consistent with anaphylaxis, including generalized urticaria, facial and oropharyngeal swelling, respiratory distress with wheeze and stridor, hypotension, and syncope. The ED team initiates the anaphylaxis protocol: intramuscular epinephrine, supplemental oxygen, airway assessment and preparation for advanced airway if needed, intravenous access, fluids, H1/H2 antihistamines, and systemic corticosteroids. The patient is monitored for biphasic reaction and admitted for observation overnight given the severity of the reaction and requirement for multiple medication doses. Documentation specifically notes the temporal relationship to the meningococcal vaccine administered earlier the same day and records the vaccine product, lot number, and site of administration. Billing for the event includes the HCPCS Level II diagnosis-based code M1160 indicating anaphylaxis due to meningococcal vaccine occurring on or before the patient’s 13th birthday. Typical sites of service for this code include outpatient immunization clinics, urgent care centers, emergency departments, and inpatient pediatric observation units.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work required is substantially greater than typical due to management of severe anaphylaxis related to the vaccine. |