Summary & Overview
HCPCS M1461: Chronic Hepatitis C Diagnosis
HCPCS Level II code M1461 denotes a patient diagnosis of chronic hepatitis C and is used to document services tied to the assessment and ongoing management of chronic hepatitis C infection. Nationally, accurate use of diagnosis codes for chronic hepatitis C matters for care coordination, quality measurement, and appropriate billing across outpatient and specialty care settings. Key payers commonly involved in coverage decisions and claims adjudication include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. This publication provides a concise overview of clinical and billing context for M1461, describing the service type and typical sites of service, and summarizes what readers will learn: clinical context for chronic hepatitis C as it relates to billing, payer coverage landscape, common documentation practices, and related administrative considerations. Where specific payer policies or modifiers are relevant, readers will find directions on where to locate policy language and coding guidance. Data not available in the input will be identified as such rather than inferred. The content is intended for national audiences including coding professionals, billing managers, and clinical administrators seeking a clear reference on HCPCS Level II code M1461 and its role in documenting chronic hepatitis C.
Billing Code Overview
HCPCS Level II code M1461 represents a patient diagnosis for chronic hepatitis C. The code is used to indicate services associated with the assessment, management, or documentation of chronic hepatitis C infection.
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Service type: Diagnostic assessment and ongoing disease management related to chronic hepatitis C
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Typical site of service: Outpatient clinic or ambulatory care settings, including specialty hepatology or infectious disease clinics
Clinical & Coding Specifications
Clinical Context
A 54-year-old patient with a history of intravenous drug use presents to a hepatology clinic after positive hepatitis C antibody testing and detectable hepatitis C RNA. The patient undergoes evaluation for chronic hepatitis C, including a focused medical history, physical exam for stigmata of liver disease, laboratory testing (HCV RNA quantification, genotype testing, liver function tests, complete blood count, coagulation studies), noninvasive liver fibrosis assessment (transient elastography or serum fibrosis panels), and counseling regarding antiviral treatment options. The clinical workflow includes intake and documentation of chronic hepatitis C diagnosis, ordering and review of labs and imaging, care coordination for initiation of direct-acting antiviral therapy, immunization review (hepatitis A and B), and follow-up scheduling to assess treatment response and sustained virologic response (SVR) at 12 weeks post-treatment. Typical sites of service are outpatient hepatology or infectious disease clinics, hospital outpatient departments, and community health centers that manage chronic hepatitis C care.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when an E/M visit is performed on the same day as a diagnostic or minor procedure and the E/M is distinct from the procedure-related work |