Summary & Overview
HCPCS M1394: Stages I–III Breast Cancer
HCPCS Level II code M1394 represents services associated with stages I–III breast cancer, encompassing early and locally advanced disease management. This code captures oncology care delivered in outpatient and ambulatory settings where patients receive systemic therapy, radiation planning, surgical follow-up, and related supportive services. Nationally, codes like M1394 matter because they link clinical staging to billing workflows and influence coverage decisions and care coordination across payers.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for this code, typical sites of service, and which major payers commonly cover services tied to this staging designation. The publication also outlines benchmarking considerations and policy updates affecting billing and reimbursement for oncology services tied to tumor stage reporting.
The content provides practical reference points for billing, coding teams, and revenue cycle staff seeking clarity on when M1394 applies, how it relates to clinical staging, and what to expect from major commercial and public payers. Data not available in the input for specific modifiers, associated taxonomies, ICD-10 pairings, and precise reimbursement benchmarks.
Billing Code Overview
HCPCS Level II code M1394 denotes Stages I–III breast cancer. The code represents care related to treatment or services for patients diagnosed with early to locally advanced breast cancer (stages I through III).
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Service Type: Oncology treatment and related cancer care services
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Typical Site of Service: Hospital outpatient departments, oncology clinics, and ambulatory surgical centers where breast cancer staging and treatment (including systemic therapy, radiation planning, and related procedures) are provided.
Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.
Clinical & Coding Specifications
Clinical Context
A typical patient is a woman aged 35–70 newly diagnosed with stage I–III invasive breast cancer presenting to a multidisciplinary cancer center for breast-conserving surgery or mastectomy with sentinel lymph node biopsy or axillary dissection. The clinical workflow begins with diagnostic imaging (mammography, ultrasound, MRI as indicated), image-guided core needle biopsy confirming malignancy, and staging workup including pathology and receptor testing (ER/PR/HER2). The surgical encounter includes preoperative evaluation, anesthesia, the operative procedure (lumpectomy or mastectomy with lymph node procedure), intraoperative frozen section or specimen radiography as needed, and immediate postoperative recovery. Coordination occurs among breast surgery, medical oncology, radiation oncology, pathology, and perioperative nursing for adjuvant therapy planning. Typical sites of service are hospital inpatient, hospital outpatient surgical center, and ambulatory surgery center depending on procedure complexity and patient comorbidities.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased Procedural Services | Use when work, time, and intensity substantially exceed usual for the procedure due to extensive resection or reconstruction. |
23 |