Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerBilling CodesEpisode of CareHCPCS hcpcs-level-ii-m1111-episode-of-care-initiation-documentation
    Ask Trek AI about this page

    HCPCS M1111: Start of Episode of Care

    HCPCS Level II code M1111 documents the start of an episode of care as recorded in the medical record; this code represents a clinical administrative marker used to indicate initiation of a defined care episode, typically associated with care coordination or case management services provided in outpatient or ambulatory clinic settings where episode tracking and care planning begin.

    For related coverage guidance, see recent payer policy updates: Adult Foster Care, Group Adult Foster Care Clinical Coverage Criteria, Home Health Care Payment Policy.

    Customize your policy alerts

    Sign up for hcpcs M1111 policy alerts

    Get alerted when payer policies referencing M1111 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Table of contents

    Progress1 / 7

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • Facility ComparisonBeds, revenue & payer mix
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    Clinical & Coding Specifications

    Clinical Context

    A patient presents to an outpatient clinic or ambulatory surgery center for initiation of an episode of care documented in the medical record using billing code M1111. Typical patients include those referred for a new course of rehabilitative services, durable medical equipment (DME) management, or commencement of a structured treatment plan requiring formal episode tracking. Example scenario: a 64-year-old patient with new onset knee osteoarthritis is evaluated by an orthopedic physician and physical therapist. The clinician documents the start of the episode of care, including baseline functional status, treatment goals, care plan, and planned interventions, and records the episode start date in the medical record to support M1111 billing.

    Typical clinical workflow:

    • The patient is registered and triaged in an outpatient clinic, ambulatory surgery center, or physical therapy clinic.

    • The ordering or treating clinician performs evaluation and documents the start of an episode of care in the medical record, including history, baseline measures, treatment plan, and anticipated length of episode.

    • Relevant diagnostics or assessments (imaging, functional scores) are obtained as needed.

    • The clinic coder assigns M1111 to indicate the documented start of the episode; associated CPT codes for evaluations, procedures, or therapy sessions are billed separately according to services rendered.

    • Modifiers are appended where clinically indicated to reflect unusual circumstances (e.g., increased complexity, discontinued services, unusual anesthesia) per payer rules.

    Typical site of service:

    • Outpatient clinic

    • Ambulatory surgery center

    • Physical therapy or rehabilitation facility

    Typical patient scenario:

    • New or reactivated episode of care requiring documentation of episode start for care management, authorization, or DME rental/loaner initiation.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99203Office or other outpatient visit for the evaluation and management of a new patient, typically 30 minutesUsed when a comprehensive new patient E/M visit documents the start of the episode and provides the evaluation supporting M1111.
    97161Physical therapy evaluation (low complexity)Often performed at episode initiation to establish baseline function and plan therapy associated with the episode.
    97750Physical performance test or measurement (e.g., timed walk)Performed at the start of an episode to document baseline functional status.
    11042Debridement, subcutaneous tissue (example surgical procedure)May be performed early in an episode of wound care and documented alongside the episode start.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207P00000X
    207L00000X
    261QR0200X
    208M00000X
    103TP2700X
    225XP0019X
    170100000X
    3104A0625X

    Related ICD-10-CM Codes

    27 rows

    ICD-10-CM CodeDescription
    E11.9Type 2 diabetes mellitus without complications
    E78.5Hyperlipidemia, unspecified
    F32.9Major depressive disorder, single episode, unspecified
    F41.9Anxiety disorder, unspecified
    G43.909Migraine, unspecified, not intractable, without status migrainosus
    H52.4Presbyopia
    I10Essential (primary) hypertension
    J02.9Acute pharyngitis, unspecified
    J06.9Acute upper respiratory infection, unspecified
    K21.9Gastro-esophageal reflux disease without esophagitis

    Showing 1–10 of 27

    Related Payer Policy Updates

    Specialty: Home Health & Hospice1 / 2

    10 rows

    PolicyPayerEffective Date
    Adult Foster Carefallon_community_health_plan_inc2027-01-27
    Group Adult Foster Care Clinical Coverage Criteriafallon_community_health_plan_inc2027-01-01
    Home Health Care Payment Policyfallon_community_health_plan_inc2026-12-01
    Private Duty Nursing in the Home SettingAnthem2026-10-01
    Home Health, Skilled, and Custodial Care Services (for Nebraska Only)UnitedHealthcare2026-10-01
    Home Health, Skilled, and Custodial Care Services (for Tennessee Only)UnitedHealthcare2026-10-01
    Home Health, Skilled, and Custodial Care Services (for Kansas Only)UnitedHealthcare2026-09-01
    Private Duty Nursing Services (for Nebraska Only)UnitedHealthcare2026-09-01
    Home Health, Skilled, and Custodial Care Services (for New Jersey Only)UnitedHealthcare2026-09-01
    Home Health, Skilled, and Custodial Care Services (for Idaho Only)UnitedHealthcare2026-08-01

    Related Codes

    HCPCS-LEVEL-II-M1120-PATIENT-SELF-DISCHARGED-EARLY

    HCPCS Level II M1120: Ongoing Care Interrupted by Patient Self-Discharge

    HCPCS-M1106-START-OF-EPISODE-OF-CARE

    HCPCS Level II M1106: Start of Episode of Care Documentation

    HCPCS-M1107-DEGENERATIVE-NEUROLOGICAL-DIAGNOSIS-DOCUMENTATION

    HCPCS Level II M1107: Documentation of Degenerative Neurological Condition

    HCPCS-M1108-HOME-PROGRAM-REFERRAL-CONSULTATION-ONLY

    HCPCS Level II M1108: Ongoing Care Not Clinically Indicated

    HCPCS-M1109-ONGOING-CARE-INTERRUPTED-DUE-TO-EARLY-DISCHARGE

    HCPCS Level II M1109: Ongoing Care Interrupted by Hospitalization or Surgery

    HCPCS-M1110-EARLY-SELF-DISCHARGE-CARE-INTERRUPTED

    HCPCS Level II M1110: Ongoing Care Not Possible — Patient Self-Discharged

    HCPCS-M1112-DEGENERATIVE-NEUROLOGICAL-DIAGNOSIS-DOCUMENTATION

    HCPCS Level II M1112: Documentation of Degenerative Neurological Diagnosis

    HCPCS-M1113-ONGOING-CARE-NOT-CLINICALLY-INDICATED-HOME-PROGRAM-REFERRAL-CONSULTATION

    HCPCS Level II M1113: Ongoing Care Not Clinically Indicated

    HCPCS-M1114-CARE-DISCONTINUED-DUE-TO-HOSPITALIZATION-OR-SURGERY

    HCPCS M1114: Ongoing Care Interrupted by Hospitalization or Surgery

    HCPCS-M1115-PATIENT-SELF-DISCHARGE-INTERRUPTED-CARE

    HCPCS Level II M1115: Patient Self-Discharged, Ongoing Care Not Possible

    Showing 1–10 of 37

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    97001Physical therapy evaluation (historical CPT older code)Historical use; when documented as the initial therapy evaluation it supports episode initiation documentation.