M1375 (HCPCS) Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1375: Additional Rheumatoid Arthritis Encounter

HCPCS Level II code M1375 designates an additional encounter for patients with a rheumatoid arthritis (RA) diagnosis that occurs at least 90 days before or after another RA encounter within the performance period. Nationally, this code captures discrete RA-related encounters used in performance measurement and care continuity tracking. It is relevant for clinicians, coders, and payers focused on chronic disease management and quality reporting.

Key payers in scope include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what M1375 represents, typical service settings, and the role the code plays in measuring repeat or interval RA encounters. The publication outlines expected use cases, reporting context, and where to look for associated guidance. Any missing specifics such as associated taxonomies or linked ICD-10 diagnoses are noted as unavailable in the input.

This brief provides operational clarity for billing and coding teams handling RA follow-up encounters, and serves as a reference for payer contract reviewers and quality measurement leads assessing encounter-based RA metrics.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1375HCPCS Level IIrheumatoid arthritisambulatory careoutpatient visitperformance measurementquality reporting

Billing Code Overview

HCPCS Level II code M1375 indicates an additional encounter with a rheumatoid arthritis (RA) diagnosis during the performance period or prior performance period that occurs at least 90 days before or after an encounter with an RA diagnosis during the performance period. The service represents an episodic follow-up or separate encounter tied to rheumatoid arthritis management.

Service type: Ambulatory office or outpatient encounter for rheumatoid arthritis follow-up or assessment
Typical site of service: Physician office, outpatient clinic, or ambulatory care setting

Clinical & Coding Specifications

Clinical Context

A typical patient is a 58-year-old individual with a documented diagnosis of rheumatoid arthritis who presents for outpatient follow-up visits over a performance period for quality measurement or registry reporting. The billing code M1375 is used to indicate an additional encounter with an RA diagnosis that occurs at least 90 days before or after a documented encounter with an RA diagnosis during the performance period. The clinical workflow begins with a scheduling or triage contact, in-person or telehealth evaluation by a rheumatology clinician or primary care provider, medication reconciliation, symptom assessment (joint pain, swelling, morning stiffness), review of disease activity measures (for example, CDAI or RAPID3), and documentation of diagnosis and encounter dates. Laboratory testing (for example, inflammatory markers, medication safety labs) or imaging may be ordered as clinically indicated. The encounter is coded with the primary visit CPT or E/M code appropriate to the visit and M1375 is appended when the visit meets the timing and diagnostic criteria described by the code to support registry or performance reporting. Typical sites of service include outpatient clinic, physician office, rheumatology specialty clinic, and telehealth/virtual visit platforms. Common patient scenario: a patient with stable rheumatoid arthritis seen for medication follow-up 120 days after a prior RA visit; the clinician documents the RA diagnosis and relevant assessment, and M1375 is reported to indicate the additional qualifying encounter relative to the performance period.

Coding Specifications

Modifier

HCPCS M1413: PD-L1 Positive Prior to First-Line Immune Checkpoint Inhibitor Therapy

HCPCS-M1254-PATIENT-DECEASED-ON-HOME-HEALTH-SURVEY-CONTACT

HCPCS Level II M1254: Patient Deceased on Home Health Survey Contact

HCPCS-M1430-RETINAL-EXAM-NO-RETINOPATHY-BOTH-EYES-SEVERITY-DOCUMENTED

HCPCS M1430: Retinal Exam, No Retinopathy in Both Eyes with Severity Documented

HCPCS-M1285-MAMMOGRAPHY-RESULTS-NOT-DOCUMENTED-REVIEW

HCPCS Level II M1285: Mammography Results Not Documented and Reviewed

HCPCS-M1164-DEMENTIA-HISTORY-MEASURE

HCPCS M1164: Dementia Documented in Patient History

HCPCS-M1471-MEDICARE-PART-B-HEP-B-VACCINE-COVERAGE-STATUS

HCPCS M1471: Medicare Part B Hepatitis B Vaccine Coverage Status

HCPCS-M1465-PATIENT-FOLLOW-UP-MORE-THAN-180-DAYS

HCPCS M1465: Patient Follow-Up More Than 180 Days After Treatment

HCPCS-M1261-KIDNEY-WAITLIST-PRIOR-TO-DIALYSIS

HCPCS Level II M1261: Kidney/Kidney-Pancreas Waitlist Prior to Dialysis

HCPCS-M1193-MMR-MSI-PATHOLOGY-REPORT-RECOMMENDATION-TESTING

HCPCS M1193: Surgical Pathology Report for MMR/MSI Testing

HCPCS-M1448-PERSONALITY-DISORDER-DIAGNOSIS-MEASURE

HCPCS M1448: Personality Disorder Diagnosis for Measurement

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Taxonomy Code	Specialty	Notes
207RH0000X	Rheumatology	Primary specialty managing rheumatoid arthritis diagnosis and follow-up visits.
207Q00000X	Internal Medicine	Often provides ongoing chronic disease management for RA patients.
208000000X	Family Medicine	Provides primary care follow-up and coordination for RA patients.
363L00000X	Nurse Practitioner	Commonly delivers routine follow-up visits and medication management in outpatient settings.
367A00000X	Physician Assistant	Frequently provides clinic encounters for chronic disease follow-up under supervising physician arrangements.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M05.79`	Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement	Representative RA diagnosis used to document active disease across multiple joints and support performance reporting tied to encounters coded with `M1375`.
`M06.9`	Rheumatoid arthritis, unspecified	Commonly used when detailed subclassification is not documented; applicable to encounter coding and performance measures requiring an RA diagnosis.
`M05.89`	Rheumatoid arthritis with rheumatoid factor of other specified sites	Used when RA involves specified sites relevant to clinical assessment during follow-up encounters.
`M06.0`	Seronegative rheumatoid arthritis	Used for RA presentations without seropositivity; relevant to treatment decisions documented during qualifying encounters.
`M05.79`	Rheumatoid arthritis with rheumatoid factor, multiple sites	(Duplicate listing intentionally avoided in practice; included here to reflect common coding patterns)

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 outpatient follow-up visit code used for RA medication management and symptom assessment; often the primary encounter code with `M1375` appended for performance reporting.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for more complex follow-up visits with expanded management and documentation; may accompany `M1375` when additional encounter meets timing criteria.
`99203`	Office or other outpatient visit for the evaluation and management of a new patient, typically 30 minutes	Used when a patient with RA presents as a new patient to the practice; `M1375` may still apply for timing relative to performance periods if criteria are met.
`99204`	Office or other outpatient visit for the evaluation and management of a new patient, typically 45 minutes	Used for comprehensive new patient evaluations when more extensive history, exam, and decision making are required; relevant when establishing RA care.
`99406`	Smoking and tobacco use cessation counseling visit, intermediate	Counseling services commonly provided during RA visits to address modifiable risk factors; may be performed during an encounter counted by `M1375`.

`22`	Increased procedural services	Use when services provided are substantially greater than typically required and documentation supports greater work.
`23`	Unusual anesthesia	Use when general anesthesia is medically necessary for a procedure normally performed without it.
`52`	Reduced services	Use when a service is partially reduced or not completed at full scope.
`53`	Discontinued procedure	Use when a procedure is started but discontinued due to patient condition or unforeseen circumstances.
`54`	Surgical care only	Use when only the surgical portion is furnished and other providers report pre/post-op care.
`55`	Postoperative management only	Use when only postoperative care is furnished by the reporting provider.
`56`	Preoperative management only	Use when only preoperative care is furnished by the reporting provider.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons on distinct portions of a procedure.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist billing in Medicare Part B	Use when services are furnished by an eligible non-physician practitioner under Medicare rules.
`CQ`	Service furnished by a clinical psychologist	Use when the service is provided by a qualified clinical psychologist.
`QK`	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals	Use when physician medical directs multiple concurrent anesthetics.
`QX`	CRNA service with medical direction by a physician	Use when a CRNA provides anesthesia under medical direction.
`QY`	Medical direction of anesthesia services	Use when physician medically directs anesthesia services provided by an anesthetist.

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