Summary & Overview
HCPCS M1182: Ineligibility Due to Pre-existing Inflammatory Bowel Disease
HCPCS Level II code M1182 denotes patients who are not eligible for a particular service or therapy because of pre-existing inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease. The code is used to document an exclusion based on clinical history and can affect coverage determinations and service authorization nationally. Its use matters for payers and providers because it clarifies clinical contraindications that may preclude interventions such as certain immunomodulatory therapies, biologicals, or other procedures where IBD is a documented risk factor.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for M1182, typical service settings where the code is applied, and what to expect when this exclusion is documented on a claim. The publication summarizes benchmarks and payer coverage considerations, outlines common claim modifiers associated with complex cases, and highlights policy implications related to documenting pre-existing IBD as an exclusion. Data not available in the input is clearly noted where applicable.
Billing Code Overview
HCPCS Level II code M1182 indicates patients who are not eligible due to pre-existing inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn's disease. This code documents exclusion criteria related to IBD status for a service or coverage determination.
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Service type: Eligibility/exclusion documentation related to medical therapies or services where IBD is a contraindication or exclusion.
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Typical site of service: Administrative or clinical settings where eligibility determinations are made, including outpatient clinics, specialty practices, infusion centers, and payer/submission workflows.
Clinical & Coding Specifications
Clinical Context
A 34-year-old patient with a documented history of Crohn's disease presents for consideration of a non-IBD-related biologic infusion. The treatment team reviews eligibility criteria and determines the patient is ineligible for the planned therapy due to active inflammatory bowel disease. Typical workflow: outpatient infusion center or specialty clinic visit; intake includes verification of diagnosis, medication reconciliation, informed consent discussion, and documentation of medical contraindication. The patient encounter is coded to reflect a non-eligible status due to pre-existing inflammatory bowel disease, with clinical notes documenting the specific IBD diagnosis (e.g., ulcerative colitis or Crohn's disease), current activity or severity, and the decision rationale. Typical site of service: outpatient infusion center, specialty ambulatory clinic, or hospital outpatient department. Service type: patient ineligibility determination and documentation for a therapeutic service or supply coded under HCPCS Level II M1182 indicating exclusion due to pre-existing IBD.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When the work required is substantially greater than typically required for the service due to complexity of documenting exclusion for IBD |