Summary & Overview
HCPCS M1412: Metastatic NSCLC with Targetable Genomic Alterations
HCPCS Level II code M1412 designates systemic targeted therapy for patients with metastatic non–small cell lung cancer (NSCLC) harboring actionable genomic alterations such as EGFR mutations, ALK aberrations, ROS1 rearrangement, BRAF V600E, NTRK fusions, MET exon 14 skipping, and RET rearrangement. This code matters nationally as precision oncology expands the use of biomarker-directed therapies in first-line care, affecting coverage policy, prior authorization practices, and site-of-service billing for oncology infusion services. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will learn the clinical context supporting use of M1412, common service settings, and the payer landscape influencing reimbursement and administration of first-line targeted agents for metastatic NSCLC. The publication summarizes payer coverage trends and benchmarks, common billing modifiers, and operational considerations for oncology practices and health systems when administering targeted therapies tied to specific genomic alterations. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code M1412 describes care for patients with metastatic non-small cell lung cancer (NSCLC) who have specific targetable genomic abnormalities, including epidermal growth factor receptor (EGFR) mutations, ALK genomic tumor aberrations, ROS1 rearrangement, BRAF V600E mutation, NTRK 1/2/3 gene fusions, MET exon 14 skipping mutation, and RET rearrangement. The code reflects use of approved first-line targeted therapies matched to these genomic alterations.
Service Type: Systemic targeted therapy for metastatic NSCLC with actionable genomic alterations.
Typical Site of Service: Oncology infusion center, hospital outpatient department, or ambulatory infusion clinic.
Clinical & Coding Specifications
Clinical Context
A typical patient is a 62-year-old current or former smoker recently diagnosed with metastatic non–small cell lung cancer (NSCLC) whose tumor sequencing identifies a targetable driver alteration such as ROS1 rearrangement, BRAF V600E mutation, NTRK1/2/3 gene fusion, MET exon 14 skipping mutation, or RET rearrangement. The clinical workflow begins with presentation for evaluation of progressive dyspnea, cough, or new metastatic symptoms followed by imaging (CT chest, PET-CT) and tissue biopsy. Pathology confirms NSCLC and comprehensive genomic profiling (NGS) detects an actionable alteration. The oncology team documents the molecular result and initiates an approved first-line targeted therapy per tumor board or multidisciplinary consensus. Care includes baseline labs, cardiac and hepatic monitoring as indicated by the chosen agent, scheduled clinic visits for toxicity assessment and response imaging, and periodic documentation for medical necessity and authorization for the targeted agent. Typical sites of service include outpatient oncology infusion or clinic settings and, when required for diagnostic procedures, hospital-based outpatient surgery or interventional radiology for tissue biopsy.
Coding Specifications
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