M1424 Pulmonology MIPS | HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS M1424: Pulmonology Care MIPS Value Pathway

HCPCS Level II code M1424 denotes the Pulmonology care MIPS value pathway, a classification used to align pulmonary clinical services with MIPS performance measurement and reporting. Nationally, this code matters as health systems and clinicians increasingly tie reimbursement and quality reporting to value-based programs; using an explicit HCPCS Level II code for a MIPS pathway helps standardize claims-level identification of pathway-related services and supports national benchmarking and program administration.

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, typical sites of service, and the types of reporting and billing scenarios where the code may appear. The publication outlines expected benchmarks, implications for claims processing and payer communications, and summarizes relevant policy or program updates affecting MIPS-aligned pulmonology reporting.

This resource is intended for billing managers, compliance officers, pulmonology clinicians, and policy analysts seeking a national-level summary of the code’s purpose, payer relevance, and operational considerations for integrating M1424 into billing and quality measurement workflows.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1424HCPCS Level IIPulmonologyMIPS value pathwayQuality reportingOutpatient pulmonary careHealthcare billingValue-based care

Billing Code Overview

HCPCS Level II code M1424 represents the Pulmonology care MIPS value pathway, a classification tied to performance measurement and reporting for pulmonology clinicians. The code denotes services aligned with the Merit-based Incentive Payment System (MIPS) value pathway framework for pulmonary care.

Service type: Pulmonology care and performance reporting activities

Typical site of service: Outpatient pulmonology clinics and hospital-based pulmonary practice settings

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 68-year-old patient with a history of chronic obstructive pulmonary disease (COPD) and recurrent exacerbations presents for longitudinal specialty management within a Pulmonology MIPS Value Pathway. The patient is seen in a pulmonology clinic for a comprehensive visit that includes review of symptoms (dyspnea, cough, sputum production), assessment of inhaler technique, medication reconciliation, and optimization of long-term therapy. Objective evaluation includes review of recent spirometry, pulse oximetry, and review of imaging reports (chest radiograph or CT if applicable). The clinical workflow typically includes: initial nurse intake and vitals, focused history and symptom assessment by the pulmonology provider, medication and device education, ordering or review of pulmonary function testing, coordination of referrals to pulmonary rehabilitation or home oxygen evaluation if indicated, and documentation of quality measures for the MIPS pathway. Complex visits may require extended time for decision-making, use of modifier 22 for increased procedural or service complexity documentation, or preauthorization activities for durable medical equipment (home oxygen) and advanced therapies. Typical sites of service are outpatient pulmonary clinic, hospital-based outpatient clinic, or ambulatory specialty center. Telehealth follow-up visits and care coordination activities are also common within this pathway.

Coding Specifications

Modifier	Description	When to Use
`22`

HCPCS M1335: Documentation of Reasons for Not Having Follow-Up Exam

HCPCS-LEVEL-II-M1356-PATIENTS-WHO-DIED-DURING-MEASUREMENT-PERIOD

HCPCS Level II M1356: Patients Who Died During the Measurement Period

HCPCS-M1217-SPIROMETRY-NOT-DOCUMENTED-REASON

HCPCS Level II M1217: Reason for Not Documenting Spirometry Results

HCPCS-M1244-PATIENT-PERCEIVED-PROVIDER-BEST-INTERESTS

HCPCS M1244: Patient-Reported Provider Best-Interest Response

HCPCS-M1343-PAM-LEVEL-4-OR-INVALID-RESPONSE-ASSESSMENT

HCPCS M1343: Assessment for PAM Level 4 or Invalid PAM Responses

HCPCS-M1462-HEAD-IMAGING-CLINICAL-INDICATIONS

HCPCS M1462: Head Imaging for Clinical Indications

HCPCS-M1249-PATIENT-UNDERSTANDS-IMPORTANT-TO-ME

HCPCS Level II M1249: Patient-reported Understanding of What Matters

HCPCS-M1324-INTRAVITREAL-PERIOCULAR-CORTICOSTEROID-INJECTION

HCPCS M1324: Intravitreal or Periocular Corticosteroid Injection

HCPCS-M1219-ANAPHYLAXIS-VACCINE-REACTION-ENCOUNTER

HCPCS Level II M1219: Anaphylaxis Due to Vaccine on or Before Encounter Date

HCPCS-M1374-RA-ADDITIONAL-ENCOUNTER-90-DAYS

HCPCS M1374: Additional Rheumatoid Arthritis Encounter, 90+ Days

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Taxonomy Code	Specialty	Notes
208VP0400X	Pulmonology	Board-certified pulmonary disease specialists who manage chronic lung disease and complex pulmonary care.
208D00000X	Internal Medicine	Internists who provide longitudinal care and often co-manage pulmonary conditions in outpatient settings.
363LF0000X	Physician Assistant	PAs who staff pulmonary clinics and perform follow-up, education, and procedure assistance.
207Q00000X	Family Medicine	Family physicians who provide primary care coordination and initial pulmonary evaluations.
367A00000X	Nurse Practitioner	NPs who deliver outpatient pulmonary care, patient education, and care coordination.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`J44.9`	Chronic obstructive pulmonary disease, unspecified	COPD is a primary diagnosis managed in pulmonary MIPS pathways for symptom control and exacerbation prevention.
`J45.909`	Unspecified asthma, uncomplicated	Asthma patients are managed in pulmonology pathways for control assessment and inhaler optimization.
`R06.02`	Shortness of breath	Symptom code used for patients presenting with dyspnea requiring pulmonary evaluation and treatment adjustments.
`J96.90`	Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia	Used when patients in pulmonary clinics have advanced disease requiring oxygen therapy assessment or escalation of care.
`Z79.01`	Long term (current) use of anticoagulants	Common comorbidity affecting management decisions for procedures and anticoagulation planning in pulmonology patients.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`94620`	Pulmonary stress testing; spirometry, including graphic interpretation and reporting	Performed to quantify airflow obstruction and monitor COPD progression, often ordered at or before the pulmonary clinic visit.
`94010`	Bronchospasm evaluation, spirometry; including pre- and post-bronchodilator studies	Used to assess bronchodilator responsiveness during initial or follow-up pulmonary assessment.
`94375`	Respiratory flow volume loop, spirometry	Provides detailed flow-volume loop analysis for diagnosis and monitoring, frequently reviewed in clinic.
`94640`	Pressurized or nonpressurized inhalation treatment for acute airway obstruction	Administered in clinic or ED for acute bronchospasm episodes and may be documented in the MIPS pathway when used.
`99078`	Physician or other qualified health care professional educational services, individual patient education	Used for extended patient education on inhaler technique, home oxygen use, or pulmonary rehabilitation referral when billed separately.

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