Summary & Overview
HCPCS M1405: Patients with Recurrence or Disease Progression
HCPCS Level II code M1405 designates care provided to patients experiencing disease recurrence or progression. Nationally, clear coding for recurrence/progression is important for clinical documentation, utilization tracking, and alignment with payer coverage policies for follow-up care, surveillance, and treatment modifications. Use of M1405 signals a change in clinical status that may drive additional diagnostic testing, specialist consultation, or therapeutic interventions.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code's clinical context, common settings where it is billed, and the implications for billing workflows. The publication summarizes benchmarks and policy-relevant considerations, describes typical service lines that bill this code, and identifies areas where payers often apply review or prior authorization associated with recurrence or progression scenarios.
This coverage is intended for clinicians, billing professionals, and policy analysts seeking a national perspective on how M1405 is used in practice and how it interfaces with payer policies and clinical management pathways.
Billing Code Overview
HCPCS Level II code M1405 is defined as Patients with recurrence/disease progression. This code is used to indicate services provided to patients who are experiencing a return of disease or progression of an existing condition.
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Service type: Care related to disease recurrence or progression, including evaluation and management focused on changes in clinical status
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Typical site of service: Ambulatory clinics, oncology or specialty outpatient settings, and other outpatient care locations where disease recurrence or progression is assessed and managed
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult oncology patient with documented tumor recurrence or radiographic disease progression presenting for evaluation and management or for delivery of a targeted supportive service tied to progressive disease under billing code M1405. The patient commonly arrives to an outpatient oncology clinic, cancer center, or hospital outpatient department for symptom reassessment, imaging review, and modification of the care plan. The clinical workflow includes: initial vitals and symptom-directed nursing assessment; review of recent imaging and pathology confirming recurrence or progression; multidisciplinary discussion or physician consultation to determine next-line systemic therapy, palliative interventions, or referral for clinical trial evaluation; documentation of medical necessity citing progression/recurrence; procedural scheduling if biopsies, port access, or interventional radiology procedures are required; and coordination with hospice, palliative care, or home health as indicated. Typical sites of service are outpatient oncology clinic, hospital outpatient department, and ambulatory infusion center. Common presenting problems include new or worsening pain, weight loss, new neurologic deficits, rising tumor markers, or new radiographic lesions prompting treatment change.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased Procedural Services |