HCPCS M1474: Patients with Diagnosis of Dementia

HCPCS Level II code M1474 represents services for patients with a diagnosis of dementia and denotes dementia-focused assessment, monitoring, or support care. This code matters nationally as dementia prevalence grows with an aging population and payers and providers seek standardized ways to capture cognitive-care services for quality measurement, care coordination, and claims processing. Consistent coding affects access to appropriate outpatient and home-based services and informs resource planning for geriatric and neurocognitive care.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what M1474 denotes in clinical practice, typical sites of service, and the payer landscape relevant to this service. The publication summarizes common billing contexts, benchmark considerations, and policy implications tied to coding dementia-related care. The content highlights where documentation and coding intersect with coverage policies, and it outlines gaps where additional guidance or payer-specific edits may affect reimbursement. This summary supplies clinicians, billing professionals, and policy analysts with the context needed to interpret M1474 claims activity and align clinical documentation with billing practice.

Data not available in the input for modifiers, associated taxonomies, ICD-10 diagnoses, related codes, and service line.

Billing Code Overview

HCPCS Level II code M1474 indicates services provided for patients with diagnosis of dementia. The service type is care or management related to dementia, typically involving assessment, monitoring, or support services tailored to cognitive impairment. The typical site of service is outpatient clinic or home-based care settings where dementia-focused evaluations and follow-up occur.

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Clinical Context

A typical patient is an 82-year-old individual with progressive memory loss and functional decline diagnosed with dementia. The patient presents to a memory disorder clinic or geriatrics outpatient practice accompanied by a caregiver for evaluation and ongoing management. The clinical workflow includes a focused history from the caregiver, cognitive screening (e.g., MMSE or MoCA), medication review for anticholinergic burden, assessment of safety and functional status, counseling on disease course and caregiver support, and documentation of diagnosis and care plan. Services tied to M1474 are delivered in ambulatory clinic settings such as a neurology clinic, geriatric medicine clinic, or primary care office with dementia care capabilities, and may include periodic structured visits for care coordination, counseling, and cognitive assessment. Typical visit activities include reviewing symptoms and behaviors, adjusting medications, coordinating home safety needs, and providing caregiver education and community resource referrals.

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 in addition to the dementia-related service and is distinct from the care coordination or counseling provided.

Taxonomy Code	Specialty	Notes
`207RH0000X`	Geriatric Medicine	Specialists who commonly manage dementia diagnosis, care planning, and medication management.
`2084N0400X`	Neurology	Neurologists evaluate cognitive disorders, perform neurological exams, and coordinate diagnostic workups.
`208D00000X`	Clinical Neuropsychology	Neuropsychologists perform formal cognitive testing and interpret results for dementia syndromes.
`207QG0300X`	Family Medicine	Primary care physicians provide longitudinal dementia care, medication management, and referrals.
`261QM0800X`	Nursing — Advanced Practice Registered Nurse (Geriatrics/Family)	APRNs in geriatrics or primary care deliver dementia follow-up, education, and care coordination.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F03.90`	Unspecified dementia without behavioral disturbance	Common code used to document a diagnosis of dementia when a more specific dementia type is not specified; aligns with general dementia services.
`F03.91`	Unspecified dementia with behavioral disturbance	Used when dementia care includes management of behavioral or psychological symptoms requiring targeted interventions.
`G30.9`	Alzheimer disease, unspecified	Frequently associated with dementia services; guides care planning and prognosis discussions.
`F02.80`	Dementia in other disease classified elsewhere without behavioral disturbance	Used when dementia is secondary to another neurologic condition and informs coordination with specialty care.
`F10.27`	Alcohol-induced major neurocognitive disorder, chronic	Included when cognitive impairment is related to substance use and affects management and counseling.
`F01.50`	Vascular dementia without behavioral disturbance	Relevant when cerebrovascular disease contributes to cognitive impairment; impacts secondary prevention strategies.
`G31.84`	Mild cognitive impairment, so stated	Used for patients with objective cognitive decline not meeting dementia criteria; often part of the diagnostic continuum.
`R41.3`	Other amnesia	May be used when memory loss is a prominent symptom under evaluation in the dementia care context.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Commonly performed for routine follow-up visits to assess cognitive status, medication effects, and caregiver concerns alongside dementia care.
`99406`	Smoking and tobacco use cessation counseling, intermediate, >3 minutes up to 10 minutes	May be used if brief behavior or risk counseling is provided during a dementia-related visit when relevant to comorbidity management.
`96116`	Neurobehavioral status exam, extended evaluation of patient cognitive status; typically used for brief cognition testing	Used when structured cognitive testing is performed in the office as part of dementia assessment.
`99483`	Assessment and care planning for patients with cognitive impairment, requiring an interdisciplinary approach	Often performed for comprehensive dementia care planning, including caregiver needs assessment and functional evaluation.
`G0505`	Comprehensive assessment of and care planning by an interdisciplinary team for the behavioral health or cognitive impairment	Used for complex care planning visits addressing cognition, safety, and community support systems.

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Summary & Overview