Summary & Overview
HCPCS Level II M1401: Stages I–III Breast Cancer
HCPCS Level II code M1401 denotes care for stages I–III breast cancer and functions as a clinical identifier for services tied to early and locally advanced breast malignancy. Nationally, accurate use of this code supports consistent classification of oncology care episodes, informs quality measurement, and affects claims processing across public and commercial payers.
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 M1401, typical sites of service, and payer relevance. The publication outlines benchmarking approaches, common billing considerations, and policy implications relevant to national reimbursement and reporting practices. Where specific data elements were not provided, the report notes that input is unavailable.
This summary is intended to help billing managers, oncology practice administrators, and health policy stakeholders understand the role of HCPCS Level II code M1401 in documenting and classifying services for patients with stages I–III breast cancer, and to guide further review of payer-specific coverage and billing rules.
Billing Code Overview
HCPCS Level II code M1401 indicates stages i-iii breast cancer. This code is used to identify clinical services related to the management and treatment of early to locally advanced breast cancer (stages I through III).
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Service type: Oncology diagnostic, staging, and treatment-related services
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Typical site of service: Oncology clinics, hospital outpatient departments, ambulatory surgical centers, and inpatient oncology units
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is a woman aged 35–75 diagnosed with Stage I–III invasive breast carcinoma presenting for oncologic management that may include surgical staging, lumpectomy or mastectomy, and adjuvant therapies. The clinical workflow begins with diagnostic imaging (mammography, ultrasound, MRI) and core needle biopsy confirming malignancy. Preoperative evaluation includes tumor board review, staging studies, and planning for sentinel lymph node biopsy versus axillary dissection. Operative care is delivered in an outpatient or inpatient surgical setting depending on procedure complexity and comorbidities. Postoperative care involves pathology review, possible chemotherapy or radiation oncology referral, and ongoing surveillance.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work required is substantially greater than typically required (document rationale). |
23 | Unusual anesthesia | Use when general anesthesia is medically necessary for a procedure normally performed with local/regional anesthesia. |