Summary & Overview
HCPCS M1378: Documentation of Medical Reason for Not Recommending 10-Year Follow-Up
HCPCS Level II code M1378 denotes clinician documentation of medical reasons for not recommending the standard 10-year follow-up interval after colorectal screening. The code is used when factors such as inadequate bowel preparation, personal or family history of colonic polyps, advanced patient age with no adenoma, limited life expectancy, or other medical considerations warrant a shorter or otherwise modified surveillance plan. Nationally, clear documentation of these reasons supports clinical decision-making, continuity of care, and appropriate use of surveillance resources.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn the clinical context for using this code, typical sites of service, and the documentation purpose it serves. The content covers benchmarks and policy-relevant considerations tied to surveillance interval justification, highlights common clinical scenarios that prompt use of the code, and outlines how payers and programs recognize documentation-based codes in colorectal surveillance workflows. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code M1378 documents the medical reason(s) for not recommending a 10-year follow-up interval after colorectal screening (examples include inadequate bowel preparation, familial or personal history of colonic polyps, patient age ≥ 66 with no adenoma, life expectancy < 10 years, or other medical reasons). This code captures clinician documentation explaining why the typical decade-long surveillance interval is inappropriate for a specific patient.
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Service type: Documentation of medical justification for altered colorectal surveillance interval
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Typical site of service: Outpatient gastroenterology clinic or endoscopy center where colonoscopy findings and follow-up recommendations are determined
Clinical & Coding Specifications
Clinical Context
A 72-year-old patient presents for a screening colonoscopy visit. During pre-procedure assessment the gastroenterologist documents that the patient had prior colonoscopies with no adenomas identified, but due to the patient’s age being >= 66 years and an estimated life expectancy of less than 10 years from comorbidities (severe congestive heart failure and advanced chronic obstructive pulmonary disease), the clinician elects not to recommend a routine 10-year follow-up interval. Alternatively, documentation may cite inadequate bowel preparation during the current exam, a personal or familial history of colonic polyps, or other medical reasons (for example, frailty or evolving terminal illness) that justify a shorter or no surveillance interval.
In the clinical workflow, the endoscopist performs the colonoscopy, documents findings and bowel prep quality, and completes a formal note specifying the medical reason(s) for deviating from a standard 10-year follow-up. This documentation is used to support billing of M1378 (documentation of medical reason(s) for not recommending a 10 year follow-up interval) and is placed in the procedure report, communicated to the primary care clinician, and incorporated into the after-visit summary sent to the patient.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |