HCPCS M1483: HCV Sustained Virological Response (20 Weeks–12 Months) - OpenPayer

Summary & Overview

HCPCS M1483: HCV Sustained Virological Response (20 Weeks–12 Months)

HCPCS Level II code M1483 documents patients with hepatitis C virus (HCV) who achieve a sustained virological response (SVR), evidenced by a negative/undetectable HCV RNA result on an HCV RNA test (CPT 87522 or CPT 87521) occurring 20 weeks to 12 months after the first positive HCV RNA within the denominator identification period. This measure captures a clinically meaningful endpoint—viral clearance after HCV treatment or spontaneous clearance—which has implications for patient outcomes, public health surveillance, and quality measurement nationally.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical intent and service context, expected sites of service for testing, and what to expect in payer coverage discussions. The publication also outlines benchmarks and performance measure considerations tied to SVR reporting, relevant policy updates affecting HCV testing and reporting, and the clinical context for timing of confirmatory RNA testing. Data not available in the input is noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1483HCPCS Level IIHCVsustained virological responseviral clearancelaboratory testinginfectious diseasehepatologyquality measure

Billing Code Overview

HCPCS Level II code M1483 indicates patients who achieve a sustained virological response (SVR) for hepatitis C virus (HCV), defined by a negative/undetectable HCV RNA result on an HCV RNA test (CPT 87522 or CPT 87521) that occurred 20 weeks to 12 months after the first positive/detectable HCV RNA test within the denominator identification period.

Service Type: Laboratory-confirmed HCV sustained virological response measurement

Typical Site of Service: Clinical laboratory testing associated with outpatient infectious disease, hepatology, or primary care follow-up

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 52-year-old patient with chronic hepatitis C virus (HCV) infection completes antiviral therapy and enters surveillance to confirm sustained virological response (SVR). Twenty-four weeks after an initial detectable HCV RNA, the clinician orders an HCV RNA quantitative or qualitative assay to confirm clearance. The laboratory performs CPT 87522 or CPT 87521 testing and reports an undetectable HCV RNA result within the 20-week to 12-month window after the first positive HCV RNA identified during the denominator period. The result is documented in the electronic medical record, communicated to the patient, and used to close the quality measure denominator for SVR.

Service Type: Laboratory diagnostic testing for HCV RNA to document SVR.
Typical Site of Service: Outpatient laboratory, hospital outpatient clinic, community phlebotomy center, or specialty infectious disease/hepatology clinic with lab draw capabilities.
Typical Patient Scenario: A patient treated with direct-acting antivirals (DAAs) returns for follow-up. A venous blood draw is obtained and sent for CPT 87522 (HCV RNA by quantitative or qualitative nucleic acid amplification) or CPT 87521 per lab protocol. A negative/undetectable HCV RNA result obtained between 20 weeks and 12 months after the first positive HCV RNA during the measurement period documents SVR and is recorded for reporting and care planning.

Coding Specifications

HCPCS M1253: Ambulatory Palliative Care Patient Disavowal

HCPCS-M1168-INFLUENZA-VACCINE-SEASONAL-MEASUREMENT-WINDOW

HCPCS Level II M1168: Seasonal Influenza Vaccination within Measurement Window

HCPCS-M1305-PNEUMOCOCCAL-VACCINE-ADULT-IMMUNIZATION

HCPCS Level II M1305: Adult Pneumococcal Vaccination

HCPCS-M1317-COUNSELING-CSP-CONNECTION-OPT-OUT

HCPCS M1317: Counseling on Community Service Provider Connection, Patient Opt-Out

HCPCS-M1313-TOBACCO-SCREENING-NOT-PERFORMED

HCPCS M1313: Tobacco Screening or Cessation Intervention Not Performed

HCPCS-M1271-PATIENTS-WITH-DEMENTIA

HCPCS Level II M1271: Patients with Dementia

HCPCS-M1203-ACE-ARB-THERAPY-NOT-PRESCRIBED-REASON-NOT-GIVEN

HCPCS M1203: ACE inhibitor or ARB therapy not prescribed, reason not given

HCPCS-M1386-MELANOMA-EXCISIONAL-SURGERY-COHORT-STAGING-0-II

HCPCS Level II M1386: Excisional Surgery Cohort for Melanoma Stages 0–II

HCPCS-M1492-PATIENT-NO-FALL-REPORTED

HCPCS Level II M1492: Patient Did Not Report a Fall

HCPCS-M1250-PATIENT-FELT-HEARD-UNDERSTOOD

HCPCS M1250: Patient Felt Heard and Understood by Provider

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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 for counseling or management occurs on the same day as blood draw for HCV RNA testing and documentation supports a distinct service
`26`	Professional component	Use when billing only the physician interpretation portion of the laboratory test (rare for automated HCV RNA assays)
`TC`	Technical component	Use when billing only the laboratory or facility component that performs the assay
`59`	Distinct procedural service	Use when HCV RNA testing is a distinct service from other diagnostic tests performed the same day and documentation supports separation
`90`	Reference (outside) laboratory	Use when the specimen is sent to an outside reference laboratory for testing
`91`	Repeat clinical diagnostic laboratory test	Use when a repeat HCV RNA test is performed on the same day to confirm results per clinical protocol
`XE`	Separate encounter	Use when the HCV RNA test is performed during a separate encounter not overlapping other services
`XP`	Separate practitioner	Use when the performing practitioner is different from the ordering practitioner and services are distinct
`XZ`	Statutory exclusion	Use when billing requires designation that the service is distinct and not normally bundled
`RT`	Right side	Not typically applicable to blood tests; reserved for laterality coding if required by payer

Taxonomy Code	Specialty	Notes
`207RH0000X`	Infectious Disease	Providers managing HCV therapy and follow-up; order and interpret HCV RNA testing
`207P00000X`	Gastroenterology	Hepatology management of chronic HCV and SVR confirmation
`207L00000X`	Internal Medicine	Primary care clinicians who order HCV testing and coordinate follow-up
`363LF0000X`	Clinical Laboratory Director	Laboratory oversight and result validation for HCV RNA assays
`174400000X`	Nursing — Hepatology or Infusion Nurse	Phlebotomy and patient education during follow-up visits

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.	Data not available in the input.	Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`87521`	Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis C virus, direct probe technique (e.g., branched DNA)	Alternative methodology for HCV RNA detection; may be used for initial or follow-up viral load testing
`87522`	Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis C virus, amplified probe technique (e.g., RT-PCR)	Commonly used quantitative/qualitative HCV RNA assay to document undetectable virus for SVR confirmation
`86304`	Hepatitis C antibody; initial screening test	Often performed earlier in the diagnostic cascade to establish prior exposure before RNA testing
`36415`	Collection of venous blood by venipuncture	Phlebotomy service required to obtain specimen for HCV RNA testing
`83876`	Molecular pathology procedure, amplification, probe; quantitative, single target (if used by specific labs)	May be used in some labs to bill specific molecular methods related to HCV RNA quantitation

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