Summary & Overview
HCPCS Level II M1364: 10-Year ASCVD Risk Score ≥20%
HCPCS Level II code M1364 documents a calculated 10-year ASCVD risk score of 20 percent or greater during the performance period. The code captures a high-risk cardiovascular risk-stratification result that informs preventive care strategies at a national level. Capturing elevated ASCVD risk is clinically important because it identifies patients who may be eligible for intensified risk-reduction interventions and population health outreach.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what the code represents, payer coverage context, and the clinical settings where the measure is typically recorded. The publication outlines benchmarks and reporting expectations where available, highlights how the code integrates with preventive cardiovascular care workflows, and summarizes policy and billing considerations relevant to national payer programs.
The report provides: an explanation of clinical intent and typical site of service; payer coverage patterns and implications for coding and reporting; common modifiers and related administrative elements (where provided); and guidance on interpreting M1364 in quality measurement and performance reporting. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code M1364 indicates a calculated 10-year ASCVD risk score of >= 20 percent during the performance period. This code represents a clinical risk-stratification result used to identify patients at high 10-year risk for atherosclerotic cardiovascular disease (ASCVD).
Service type: Risk assessment / clinical risk calculation
Typical site of service: Outpatient clinical settings where cardiovascular risk assessment and preventive care are provided, including primary care clinics, cardiology clinics, and preventive medicine visits.
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult aged 40–79 with multiple cardiovascular risk factors seen in primary care or a preventive cardiology clinic. During a chronic care visit, the clinician documents smoking status, blood pressure, lipid panel, diabetes status, age, sex, and race to calculate a 10-year atherosclerotic cardiovascular disease (ASCVD) risk score. The calculated score is documented as ≥ 20% for the performance period. Workflow: the medical assistant obtains vitals and updates medication list; the clinician reviews results, inputs data into an ASCVD risk calculator (electronic health record or validated web tool), discusses risk stratification with the patient, and documents the calculated 10-year ASCVD risk score ≥ 20% in the chart. This determination may trigger guideline-directed interventions such as initiation/intensification of statin therapy, blood pressure optimization, lifestyle counseling, or referral to cardiology, with documentation of the risk value and date of calculation in the encounter note. Typical site of service: outpatient clinic, primary care office, cardiology clinic, or preventive care visit.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when substantially greater work is required to document or calculate and counsel for ASCVD risk beyond typical visit complexity. |