M1170 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1170: Influenza Vaccine Not Received

HCPCS Level II code M1170 denotes that a patient did not receive an influenza vaccine within the defined annual measurement window (July 1 prior year to June 30 measurement year). Nationally, this code is used to document absence of influenza immunization during performance measurement periods, affecting preventive care metrics, quality reporting, and population health tracking.

Key payers in scope include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on why documenting non-receipt matters for vaccination rates and quality measurement, which payers commonly accept the code, and where to look for related billing and reporting considerations. This publication covers benchmarks and reporting implications, summarizes clinical context around influenza vaccination measurement periods, and highlights policy and payer documentation expectations relevant to national quality programs.

Data elements such as common modifiers, associated taxonomies, and ICD-10 diagnoses are provided separately when available. If specific payer policies or updates exist, readers will see concise summaries of their impact on coding and reporting for immunization measures.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1170HCPCS Level IIinfluenza vaccinationvaccine refusalpreventive carequality measurementambulatory careimmunization reporting

Billing Code Overview

HCPCS Level II code M1170 indicates that a patient did not receive an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period. The service type reflected by this code is vaccine refusal or vaccine not administered during the influenza vaccination measurement window. The typical site of service for reporting this code is ambulatory/outpatient settings where vaccinations are offered or assessed, including primary care clinics, urgent care centers, and other outpatient facilities that track preventive immunization status.

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Clinical & Coding Specifications

Clinical Context

A primary care practice documents immunization quality measures for adult patients. A 68-year-old patient presents for an annual wellness visit during the measurement period. The medical record shows no influenza vaccine administered on or between July 1 of the year prior to the measurement period and June 30 of the measurement period. Clinical workflow includes review of immunization registry, patient interview about prior vaccinations, documentation of vaccine refusal or contraindication if applicable, and coding for measure reporting. In this scenario the patient either declines vaccination or there is no record of receipt; staff document the absence of influenza immunization using the billing code M1170. Typical steps: chart review, patient counseling, offer of vaccine, documentation of refusal or lack of vaccine, and submission of M1170 for quality measure capture if no vaccine was received during the specified reporting window. Typical sites of service are outpatient primary care clinics and ambulatory care settings where routine immunization assessment occurs.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS M1174: Herpes Zoster Recombinant Vaccine Series Completion

HCPCS-M1330-DOCUMENTATION-REASON-NO-FOLLOW-UP-EXAM

HCPCS Level II M1330: Documentation of Reason for No Follow-Up Exam

HCPCS-M1455-REPLACED-REVISED-DEVICE-COMPONENT

HCPCS Level II M1455: Replacement or Revision of Device Component

HCPCS-M1434-ORAL-CHEMOTHERAPY-STATUS-POST-ENCOUNTER

HCPCS M1434: Patient on Oral Chemotherapy Near Encounter

HCPCS-M1475-HUNTINGTONS-DISEASE-CARE

HCPCS Level II M1475: Huntington's Disease Care

HCPCS-M1301-TOBACCO-CESSATION-INTERVENTION

HCPCS M1301: Tobacco Cessation Intervention for Identified Tobacco Users

HCPCS-M1452-PATIENT-HISTORY-DEMENTIA

HCPCS M1452: Patient Ever Had a Diagnosis of Dementia

HCPCS-M1250-PATIENT-FELT-HEARD-UNDERSTOOD

HCPCS M1250: Patient Felt Heard and Understood by Provider

HCPCS-M1387-PATIENT-DEATH-DURING-PERFORMANCE-PERIOD

HCPCS Level II M1387: Patient Death During Performance Period

HCPCS-M1154-HOSPICE-SERVICES-MEASUREMENT-PERIOD

HCPCS M1154: Hospice Services During Measurement Period

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary clinicians performing adult immunization assessments and documentation.
`208D00000X`	General Internal Medicine	Common site for annual wellness visits and vaccine status assessment.
`363L00000X`	Public Health Clinic	Population-level immunization documentation and reporting.
`261QM0800X`	Nurse Practitioner	Frequently documents vaccine offers, refusals, and immunization counseling.
`174400000X`	Physician Assistant	Often documents immunization status and administers vaccines.

ICD-10 Code	Description	Clinical Relevance
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Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M code for an outpatient visit where influenza vaccine status is reviewed and documented; used when counseling or assessment occurs but vaccine not given.
`90471`	Immunization administration (one vaccine) by intramuscular, subcutaneous, or intradermal injection	Used when an influenza vaccine is administered; not applicable when `M1170` reports no vaccine was received, but commonly paired in workflows when vaccine is given.
`90472`	Each additional vaccine administered (list separately in addition to code for primary vaccine)	Used if multiple vaccines are given during the same visit; included for workflow context.
`G0008`	Administration of influenza vaccine, including counseling, for Medicare beneficiaries	Medicare-specific administration code used when influenza vaccine is provided; relevant as an alternate to `M1170` when vaccine is given.
`99406`	Smoking and tobacco use cessation intermediate counseling, 3-10 minutes	Example of an adjunct preventive counseling service that may be performed during the same visit where vaccine status is assessed; included as commonly performed preventive service concurrently.
`99385`	Initial comprehensive preventive medicine evaluation, new patient; 18-39 years	Preventive medicine codes used in wellness contexts where immunization status is evaluated; included as contextual CPT often associated with immunization assessment.

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