M1164 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1164: Dementia Documented in Patient History

HCPCS Level II code M1164 denotes documentation that a patient had dementia at any time during their history through the end of the measurement period. This designation is important for clinical registries, quality measurement, care planning, and risk adjustment at a national level because dementia status affects care coordination, service needs, and performance metrics across settings of care. Major national payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an explanation of the code’s clinical meaning and typical sites of service, an outline of which payers recognize or use the code in reporting and quality programs, and context on how M1164 fits into documentation and measurement workflows. The content summarizes benchmark and reporting implications, highlights common modifier usage where available, and notes where input data was not provided. Data not available in the input is indicated where relevant; no new clinical guidance or provider recommendations are given. This summary is written for a national audience interested in billing, quality reporting, and administrative classification of dementia in patient records.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1164HCPCS Level IIdementiaquality measurementclinical documentationrisk adjustmentoutpatientlong-term care

Billing Code Overview

HCPCS Level II code M1164 indicates patients with dementia any time during the patient's history through the end of the measurement period. This code is used to identify and document the presence of dementia in a patient's medical history for reporting and quality measurement purposes.

Service Type: Clinical history / diagnosis capture and quality measure reporting

Typical Site of Service: Any outpatient or inpatient clinical setting where patient history and diagnoses are documented, including primary care clinics, neurology practices, memory clinics, long-term care facilities, and hospitals.

Clinical & Coding Specifications

Clinical Context

A typical patient is an older adult with documented cognitive decline who receives ongoing longitudinal care in primary care, geriatrics, neurology, or memory clinic settings. The patient has a confirmed diagnosis of dementia recorded at any time during the patient’s history up through the end of the measurement period. Clinical workflow begins when a clinician reviews the problem list and past encounters, confirms dementia diagnosis in the medical record, and documents the diagnosis in the active problem list and encounter notes. Care activities commonly associated with this status include medication review for dementia-related drugs (e.g., cholinesterase inhibitors), safety counseling, assessment of caregiver needs, advance care planning discussions, and coordination with social work and community resources. Typical sites of service include outpatient primary care offices, geriatric clinics, neurology clinics, memory disorder centers, home health visits, and long-term care or nursing facilities. A realistic scenario: an 80-year-old patient with progressive memory loss followed in a geriatric clinic has prior neurocognitive testing and a documented diagnosis of Alzheimer disease dementia; during a routine visit the clinician confirms the history of dementia, updates the problem list, reviews medications, and documents care planning and caregiver support needs for quality measurement and coding purposes.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required to manage the patient with dementia substantially exceeds typical requirements for an encounter or procedure.

HCPCS Level II M1467: Care for Patients with Lynch Syndrome

HCPCS-M1493-FALLS-NOT-PERFORMED-MEDICAL-REASON-DOCUMENTATION

HCPCS M1493: Documentation of Falls Not Performed Due to Medical Reasons

HCPCS-M1367-ENT-QUALITY-CARE-MIPS-VALUE-PATHWAY

HCPCS M1367: Quality Care for ENT Disorders MIPS Value Pathway

HCPCS-M1203-ACE-ARB-THERAPY-NOT-PRESCRIBED-REASON-NOT-GIVEN

HCPCS M1203: ACE inhibitor or ARB therapy not prescribed, reason not given

HCPCS-M1291-FRAILTY-AND-DEMENTIA-MEDICATION-DISPENSING-OLDER-ADULTS

HCPCS M1291: Frailty with Dementia Medication Dispensing

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

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

HCPCS-M1259-DIALYSIS-PATIENT-STATUS-FIRST-YEAR

HCPCS M1259: Patient Status Documented Within First Year of Dialysis

HCPCS-M1263-HOSPICE-DIALYSIS-INITIATION-EVALUATION

HCPCS M1263: Hospice Patient Evaluation at Dialysis Initiation

HCPCS-M1347-PAM-SCORE-IMPROVEMENT-4-12-MONTHS

HCPCS M1347: PAM Score Improvement Over 4–12 Months

HCPCS-M1429-RETINAL-EXAM-RETINOPATHY-WITH-SEVERITY-DOCUMENTED

HCPCS Level II M1429: Retinal Exam Finding with Retinopathy

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Geriatric Medicine	Primary specialty that manages dementia diagnoses and ongoing care coordination.
`2084N0400X`	Neurology	Specialists who diagnose and stage neurodegenerative dementias and manage neurologic aspects of care.
`207L00000X`	Family Medicine	Primary care clinicians who document dementia on problem lists and manage chronic care.
`207R00000X`	Internal Medicine	Internists providing longitudinal management and documentation of dementia.
`363L00000X`	Neuropsychology	Providers who perform cognitive testing and contribute diagnostic documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`G30.9`	Alzheimer disease, unspecified	Common cause of dementia and frequently documented when dementia is present.
`F03.90`	Unspecified dementia, unspecified without behavioral disturbance	General code used when dementia is documented but not otherwise specified.
`F02.80`	Dementia in other diseases classified elsewhere without behavioral disturbance	Used when dementia occurs secondary to another neurologic or systemic disease.
`G31.84`	Mild cognitive impairment, so stated	Often present in the diagnostic spectrum and relevant for longitudinal documentation.
`F01.50`	Vascular dementia without behavioral disturbance	Dementia subtype due to cerebrovascular disease; relevant for management and coding.
`F03.91`	Unspecified dementia with behavioral disturbance	Used when dementia is accompanied by behavioral symptoms requiring documentation.
`G31.0`	Frontotemporal dementia	Specific dementia subtype important for specialty management and documentation.
`G20`	Parkinson disease	Parkinson disease frequently leads to Parkinson disease dementia and is relevant for coding when dementia is present.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99306`	Initial nursing facility care, per day, for the evaluation and management of a patient, typically 45 minutes	Used when initiating or documenting dementia care for a patient newly admitted to a nursing facility.
`99307`	Subsequent nursing facility care, per day, for the evaluation and management of a patient, typically 20 minutes	Used for ongoing follow-up visits documenting dementia status and care needs in a facility.
`99483`	Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, caregiver involvement, and care plan	Directly relates to comprehensive cognitive assessment and care planning for patients with dementia.
`96132`	Neuropsychological testing evaluation services by physician or psychologist, first hour	Used when formal cognitive testing is performed to support dementia diagnosis and staging.
`G0505`	Comprehensive assessment and care planning for patients requiring complex chronic care management (Medicare chronic care management)	Used for structured care planning and coordination in patients with dementia under Medicare.

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