M1402 Initial Chemotherapy (HCPCS) Reimbursement | OpenPayer

Summary & Overview

HCPCS M1402: Initial Chemotherapy Regimen Management

HCPCS Level II code M1402 denotes the initiation of a chemotherapy regimen with a defined duration under the care of an eligible clinician or group. Nationally, this code captures the point at which an oncology team formalizes an initial systemic cancer treatment plan — a critical step for care coordination, documentation, and quality measurement. Use of M1402 can affect claims processing, prior authorization conversations, and reporting tied to chemotherapy episodes of care. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will learn the clinical context and common settings where M1402 is used, typical sites of service such as infusion centers and outpatient oncology clinics, and what the code represents for episode initiation and management. The publication summarizes how M1402 fits into billing workflows, highlights typical modifiers associated with oncology services, and identifies where input was not provided. Data not available in the input includes payer-specific reimbursement levels, associated taxonomies, ICD-10 diagnoses, and related codes. The content is designed to inform billing managers, practice administrators, and policy analysts about the operational and documentation implications of HCPCS Level II code M1402 at the national level.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1402HCPCS Level IIchemotherapyoncologyinfusionoutpatientcare coordinationepisode initiation

Billing Code Overview

HCPCS Level II code M1402 describes patients receiving an initial chemotherapy regimen with a defined duration with the eligible clinician or group. This code represents the provision and management of a first-line chemotherapy plan established by the treating clinician or oncology group.

Service type: Oncology care coordination and management for an initial chemotherapy regimen
Typical site of service: Infusion center, outpatient oncology clinic, or physician office

Clinical & Coding Specifications

Clinical Context

A 58-year-old woman with newly diagnosed stage IIIB breast cancer is referred to a medical oncology practice to begin an initial, clinician-administered chemotherapy regimen with a defined duration. The oncology team performs a baseline evaluation including history, physical exam, laboratory studies (CBC, CMP), venous access placement (peripheral IV or implanted port), chemotherapy ordering and consent, and scheduling of infusion sessions. The eligible clinician documents the regimen, total planned number of cycles, start date, anticipated infusion frequency, and monitoring plan. Treatment is delivered in an outpatient infusion center or hospital outpatient infusion unit; supportive medications (antiemetics, growth factors) are administered per protocol. Billing uses the HCPCS Level II code M1402 to indicate a patient receiving an initial chemotherapy regimen with a defined duration with the eligible clinician or group, and appropriate CPT and facility charges are submitted for infusion services, drug administration, and device placement as applicable. Typical workflow steps: pre-treatment assessment and consent, venous access placement if needed, medication preparation by pharmacy, infusion administration, post-infusion monitoring, and documentation of cycle count and next appointment.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work or resources substantially exceed typical for the initial chemotherapy management visit and documentation supports increased complexity.

HCPCS M1400: Patients Who Died During Follow-Up

HCPCS-M1460-RESPIRATORY-DIAGNOSES-COPD-EMPHYSEMA-CYSTIC-FIBROSIS-ARF

HCPCS Level II M1460: Respiratory Diagnoses — COPD, Emphysema, Cystic Fibrosis

HCPCS-M1275-HOSPICE-EXCLUSION-REPORTING-PERIOD

HCPCS M1275: Hospice Exclusion From Evaluation and Reporting

HCPCS-M1303-HOSPICE-SERVICES-MEASUREMENT-PERIOD

HCPCS M1303: Hospice Services During Measurement Period

HCPCS-M1411-FIRST-LINE-IMMUNE-CHECKPOINT-INHIBITOR-NO-CHEMOTHERAPY

HCPCS M1411: First-Line Immune Checkpoint Inhibitor Without Chemotherapy

HCPCS-LEVEL-II-M1278-ELEVATED-BLOOD-PRESSURE-WITH-DOCUMENTED-FOLLOW-UP

HCPCS Level II M1278: Elevated Blood Pressure with Documented Follow-Up

HCPCS-M1399-PATIENT-LEFT-PRACTICE-DURING-FOLLOW-UP

HCPCS M1399: Patient Leaves Practice During Follow-Up

HCPCS-M1332-INADEQUATE-INITIAL-EVALUATION-FOLLOW-UP

HCPCS M1332: Inadequate Initial Evaluation or Missed 2-Week Re-evaluation

HCPCS-M1388-MELANOMA-RECURRENCE-EXAM

HCPCS M1388: Exam for Recurrence of Melanoma

HCPCS-M1250-PATIENT-FELT-HEARD-UNDERSTOOD

HCPCS M1250: Patient Felt Heard and Understood by Provider

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Taxonomy Code	Specialty	Notes
207RH0000X	Hematology/Oncology	Medical oncologists and hematologist-oncologists who prescribe and manage chemotherapy regimens.
363LP0200X	Infusion Therapy	Specialized infusion nurses or infusion clinics providing administration and monitoring.
207K00000X	Medical Oncology	Physicians focused on systemic cancer therapy and regimen management.
261QM0800X	Physician Assistant	Advanced practice clinicians who may perform evaluations, order therapy, and manage follow-up under supervision.
363LA2200X	Registered Nurse	Oncology-certified nurses who perform infusion administration and patient education.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C50.912`	Malignant neoplasm of unspecified site of right female breast	A common primary diagnosis indicating breast cancer requiring systemic chemotherapy as an initial regimen.
`C50.911`	Malignant neoplasm of unspecified site of left female breast	Indicates left-sided breast cancer for which an initial chemotherapy regimen may be prescribed.
`C80.1`	Malignant (primary) neoplasm, unspecified	Used when the primary site is not specified but systemic chemotherapy is indicated for malignancy.
`C61`	Malignant neoplasm of prostate	Solid tumor diagnosis where initial chemotherapy regimens may be used in advanced disease.
`C34.90`	Malignant neoplasm of unspecified part of unspecified bronchus or lung	Lung cancer diagnosis commonly managed with initial systemic chemotherapy regimens in appropriate stages.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`36460`	Introduction of tunneled centrally inserted central venous catheter, without subcutaneous port or pump	Performed before or at initiation when a tunneled central line is required for a defined chemotherapy regimen.
`36561`	Insertion of a port, central venous access device, implanted, reservoir (e.g., Port-A-Cath)	Commonly performed prior to initial chemotherapy regimen to provide long-term venous access.
`96413`	Chemotherapy administration, infusion technique; intravenous, infusion for antineoplastic drug, up to 1 hour, single or initial substance/drug	Used for many infusion visits during the initial regimen; billed for each qualifying infusion session.
`96415`	Each additional hour of infusion, up to 8 hours	Billed when infusion sessions exceed the base time increment represented by the initial chemotherapy administration code.
`96365`	Intravenous infusion, therapeutic, prophylactic, or diagnostic; initial, up to 1 hour	Used for administration of supportive IV medications (e.g., antiemetics) on the day of regimen initiation when applicable.

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