Summary & Overview
HCPCS Level II M1467: Care for Patients with Lynch Syndrome
HCPCS Level II code M1467 denotes services provided to patients with an established diagnosis of Lynch syndrome, a hereditary cancer predisposition syndrome. Nationally, clear coding for hereditary cancer management supports accurate care coordination, risk surveillance, and appropriate reimbursement pathways for specialty outpatient and genetic counseling services. This code matters for clinicians and billing teams because it distinguishes targeted hereditary cancer management from general oncology visit codes, enabling tracking of care delivery for a high-risk population.
Key payers addressed in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn the clinical context of M1467, typical sites of service, and what to expect in payer coverage landscapes. The publication outlines benchmark topics and policy considerations relevant to hereditary cancer services, including coding alignment, claim documentation elements, and common insurer approaches to covering genetic counseling and management for Lynch syndrome. The summary also highlights areas where payers often require specific documentation to support medical necessity and where billing teams may focus coding practices to reflect specialized care for patients with Lynch syndrome.
Billing Code Overview
HCPCS Level II code M1467 indicates services for patients with an existing diagnosis of Lynch syndrome. The service type associated with this code is genetic counseling and management related to hereditary cancer syndromes, and the typical site of service is specialty outpatient clinics, genetic counseling centers, or oncology clinics.
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Clinical & Coding Specifications
Clinical Context
A typical patient is a 42-year-old individual with a known diagnosis of Lynch syndrome who presents for surveillance and counseling in a high-risk genetics clinic. The patient has a documented pathogenic variant in an MMR gene (MLH1, MSH2, MSH6, or PMS2) and requires care coordination for cancer surveillance, genetic counseling, and risk-directed procedures. The clinical workflow begins with pre-visit chart review of prior pathology and family history, followed by an outpatient genetics or gastroenterology visit where the provider documents the Lynch syndrome diagnosis, reviews the surveillance schedule (colonoscopy intervals, endometrial surveillance options for females, and consideration of prophylactic surgery), and orders appropriate testing or referrals. During the encounter the clinician documents informed consent for surveillance procedures, communicates risk to the patient and family, and arranges referrals to colorectal surgery, gynecologic oncology, dermatology, or gastroenterology as indicated. Typical site of service is an outpatient specialty clinic (genetics clinic, gastroenterology clinic, or high-risk cancer clinic); ancillary services such as colonoscopy occur in ambulatory endoscopy centers or hospital outpatient departments. Common patient scenario modifiers include ongoing management of a known hereditary cancer syndrome, surveillance scheduling, and coordination of multidisciplinary 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 |