M1484 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1484: No Repeat HCV RNA Labs, Medical Reason

HCPCS Level II code M1484 denotes a documented clinical reason for not performing repeat HCV RNA testing, such as limited life expectancy or competing clinical priorities like active hepatocellular carcinoma or concurrent HIV/hepatitis B management. The code provides a standardized way to indicate medically justified omission of repeat viral load testing during HCV care, which affects quality measurement, clinical workflows, and claims processing on a national scale. Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find concise guidance on the code's clinical context and typical settings, an overview of payer coverage considerations, and the types of benchmarks and policy updates that influence use of the code. The publication outlines where M1484 fits in reporting and quality frameworks, reasons this documentation matters for audit and utilization review, and how the code interacts with laboratory monitoring pathways for patients with complex comorbidities. Data not available in the input is clearly noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1484HCPCS Level IIHCV RNA testinghepatologyinfectious diseaselaboratory exceptionsquality measurementambulatory care

Billing Code Overview

HCPCS Level II code M1484 indicates that a patient did not have repeat hepatitis C virus (HCV) RNA laboratory testing performed because of documented medical reasons by the clinician. Examples include limited life expectancy, delays in HCV treatment related to management of HIV or hepatitis B virus, active hepatocellular carcinoma, or decompensated cirrhosis.

Service type: Laboratory testing exception / documentation of medical reason for no repeat HCV RNA testing.

Typical site of service: Outpatient clinics, infectious disease and hepatology specialty practices, hospital outpatient departments, and other ambulatory care settings where HCV management and monitoring occur.

Clinical & Coding Specifications

Clinical Context

A 68-year-old male with chronic hepatitis C virus (HCV) infection is followed in a hepatology clinic. He has advanced hepatocellular carcinoma and limited life expectancy; the clinician documents a decision not to pursue repeat HCV RNA testing because results would not change management. The patient is on palliative treatment for liver cancer and clinic notes document medical reasons for deferring repeat HCV RNA testing, including ongoing oncologic therapy and anticipated limited benefit from antiviral therapy. The clinical workflow: initial HCV diagnosis and baseline HCV RNA testing were completed earlier. At a follow-up visit, the hepatologist documents medical rationale for no repeat HCV RNA—this documentation is entered in the medical record, the clinician selects the appropriate billing code M1484 for reporting to payors, and the visit is coded with the appropriate visit E/M or consultation CPT code as usual with M1484 appended for the claim to indicate medically documented deferral of repeat HCV RNA testing.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	When billing professional component separately for a related lab or service performed by physician.

HCPCS Level II M1175: Documentation of Medical Reason for Not Administering Zoster Vaccine

HCPCS-LEVEL-II-M1255-POSITIVE-PREGNANCY-TEST-NON-OB-VISIT

HCPCS Level II M1255: Positive Pregnancy Test During Non-Obstetric Clinic Visit

HCPCS-M1171-TD-TDAP-VACCINE-HISTORY-9-YEAR-PERIOD

HCPCS M1171: Td or Tdap Vaccination Within Prior Nine Years

HCPCS-M1497-FALLS-NOT-PERFORMED-MEDICAL-REASONS-DOCUMENTATION

HCPCS M1497: Documentation of Falls Not Performed Due to Medical Reasons

HCPCS-M1299-INFLUENZA-IMMUNIZATION-ADMINISTERED-OR-PREVIOUSLY-RECEIVED

HCPCS M1299: Influenza Immunization Administered or Previously Received

HCPCS-M1272-KIDNEY-KIDNEY-PANCREAS-TRANSPLANT-WAITLIST-MEMBERSHIP

HCPCS M1272: Kidney or Kidney-Pancreas Transplant Waitlist Membership

HCPCS-LEVEL-II-M1375-RA-ADDITIONAL-ENCOUNTER-90-DAYS

HCPCS Level II M1375: Additional Rheumatoid Arthritis Encounter

HCPCS-M1499-INTERVENTIONAL-RADIOLOGY-MIPS-VALUE-PATHWAY

HCPCS Level II M1499: Interventional Radiology MIPS Value Pathway

HCPCS-M1182-IBD-INELIGIBILITY-PRE-EXISTING-INFLAMMATORY-BOWEL-DISEASE

HCPCS M1182: Ineligibility Due to Pre-existing Inflammatory Bowel Disease

HCPCS-M1223-GLAUCOMA-PLAN-OF-CARE

HCPCS M1223: Glaucoma Plan of Care Documented

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Taxonomy Code	Specialty	Notes
`207RH0000X`	Hepatology	Specialists who manage chronic HCV and liver disease; commonly document medical reasons for laboratory deferral.
`207L00000X`	Infectious Disease	Manage HCV with comorbid infections such as HIV/HBV and may document deferrals related to concurrent therapy.
`207RC0000X`	Gastroenterology	Provide longitudinal care for liver disease and coordinate HCV testing and treatment decisions.
`208000000X`	Family Medicine	Primary care clinicians who manage chronic HCV in many settings and may document medical reasons to defer testing.
`207K00000X`	Internal Medicine	Hospitalists and internists overseeing complex patients with comorbidities influencing repeat HCV RNA testing.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C22.0`	Hepatocellular carcinoma	Active liver cancer is a documented medical reason to defer repeat HCV RNA testing when prognosis or treatment priorities render antiviral therapy nonbeneficial.
`K74.60`	Unspecified cirrhosis of liver	Advanced or decompensated cirrhosis can influence the decision to defer repeat HCV RNA testing.
`B18.2`	Chronic viral hepatitis C	Primary diagnosis for which HCV RNA testing is relevant; forms the basis for decisions about repeat testing.
`B20`	Human immunodeficiency virus [HIV] disease	Co-infection with HIV may necessitate coordination of therapies and temporary deferral of HCV RNA testing.
`B16.9`	Acute hepatitis B without delta-agent, unspecified	Coinfection or active hepatitis B may delay HCV treatment and justify documented deferral of repeat HCV RNA testing.

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	Common E/M code used when documenting the clinical decision to defer repeat HCV RNA testing during an outpatient follow-up visit.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for more complex visits where thorough documentation of medical reasons for deferring repeat HCV RNA testing is required.
`36415`	Collection of venous blood by venipuncture	Related when blood draw for HCV RNA testing is discussed but deferred; the code is commonly billed when blood is actually collected on the same visit.
`87804`	Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative	Laboratory testing that may be part of the HCV diagnostic workflow though not specific for HCV RNA; included as related lab work sometimes performed in the same clinical episode.
`87491`	Infectious agent detection by nucleic acid (DNA or RNA); Hepatitis C virus, amplification, quantification	The specific HCV RNA PCR test that would normally be repeated; `M1484` indicates that this repeat `87491` was not performed for documented medical reasons.

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