Summary & Overview
HCPCS M1452: Patient Ever Had a Diagnosis of Dementia
HCPCS Level II code M1452 documents that a patient has ever had a diagnosis of dementia. As a history-capture code, it records the presence of dementia in the medical record and is relevant for care coordination, risk stratification, quality reporting, and downstream care planning. Nationally, consistent documentation of dementia affects case management, appropriate care pathways, and population health measures.
Key payers included in this review are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of how the code is used in clinical documentation, common settings where it appears (primary care, outpatient clinics, long-term care), and the implications for billing and administrative workflows. The publication also outlines typical benchmarks and policy considerations tied to documentation-based codes, notes gaps where input data are unavailable, and provides clinical context on the role of dementia history capture in care management.
This summary is intended for a national audience of clinicians, coders, and health policy professionals seeking a concise reference on HCPCS Level II code M1452 and its relevance to documentation and administrative processes.
Billing Code Overview
HCPCS Level II code M1452 indicates that the patient ever had a diagnosis of dementia. This code is used to document a recorded history of dementia in the patient record rather than to describe a specific treatment or procedure.
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Service type: Clinical documentation / diagnostic history capture
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Typical site of service: Outpatient clinics, primary care offices, long-term care and assisted living documentation, and other ambulatory or institutional settings where patient medical history is recorded
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient is an older adult who presents for routine primary care or a cognitive assessment visit and has a documented history of dementia. The clinician documents that the patient "ever had a diagnosis of dementia" in the problem list or medical history, which supports chronic care planning, medication reconciliation, care coordination, advance care planning, and eligibility for services or quality reporting. Workflow: during an outpatient visit (primary care clinic, geriatric clinic, neurology clinic, or home health visit), the provider reviews prior notes and cognitive testing, confirms the historical diagnosis of dementia, updates the problem list, and records relevant functional status and caregiver support. This documentation may be used for billing, registry inclusion, quality measures, and to support home health or durable medical equipment needs tied to cognitive impairment.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when a distinct E/M is provided the same day as services related to dementia care (e.g., care coordination visit with a procedure later in the day). |
59 |