Summary & Overview
HCPCS Level II M1262: Patients with Transplant Before Dialysis
HCPCS Level II code M1262 designates patients who had a transplant prior to initiation of dialysis. Nationally, it identifies a distinct clinical subgroup with implications for care coordination between transplant teams and dialysis providers, affecting patient monitoring, medication management, and eligibility tracking for dialysis-related services. The code matters for accurate patient stratification and administrative reporting across payers and settings.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how M1262 is used in billing and clinical documentation, typical sites of service where the code appears, and the operational significance for payer claims processing. The publication outlines benchmarks for utilization where available, highlights relevant policy considerations for national payers, and summarizes clinical context surrounding transplant recipients who later require dialysis.
This summary serves clinicians, billing staff, and policy analysts seeking clarity on the purpose and application of HCPCS Level II code M1262, as well as payers evaluating coding capture for transplant history in pre-dialysis patient populations. Data not available in the input will be noted in relevant sections.
Billing Code Overview
HCPCS Level II code M1262 indicates patients who had a transplant prior to initiation of dialysis. This code is used to identify a specific clinical history: individuals who received an organ transplant before starting dialysis therapy.
-
Service Type: Pre-dialysis transplant status assessment
-
Typical Site of Service: Nephrology clinics, transplant centers, dialysis facilities, and outpatient specialty clinics
Clinical & Coding Specifications
Clinical Context
A 48-year-old male with end-stage renal disease (ESRD) presents to a transplant nephrology clinic for evaluation of long-term outcomes after a prior deceased-donor kidney transplant performed three years before he initiated maintenance dialysis. The patient developed chronic allograft dysfunction and eventually returned to dialysis; he now requires documentation of prior transplant status for dialysis program enrollment, access planning, and payer authorization for ongoing dialysis services. Clinical workflow: the transplant nephrologist reviews the operative and transplant clinic records, documents prior transplant status in the medical record, verifies prior transplant date and donor type, communicates transplant history to the dialysis center and vascular surgery for access planning, and submits the transplant-status billing code M1262 on the claim to indicate the patient had a transplant prior to initiation of dialysis. Relevant documentation includes transplant discharge summary, pathology/crossmatch reports, immunosuppression history, and dialysis start date. Typical site of service: outpatient transplant clinic, dialysis center intake, or hospital-based nephrology clinic. Typical patient scenario: patients with failed renal allograft transitioning back to chronic dialysis, needing coordination of care, vascular access planning, and payer notifications where prior transplant status affects coverage or care pathways.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |