M1006 HCPCS—Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1006: Disease Activity Not Assessed, Reason Not Given

HCPCS Level II code M1006 denotes that a patient’s disease activity was not assessed and no reason was provided. Nationally, this code matters for quality reporting, clinical documentation completeness, and care coordination across outpatient and ambulatory settings where routine disease activity assessment is standard practice. Proper use of M1006 affects performance metrics and administrative records that inform payer audits and quality programs.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines payer coverage considerations, common billing modifiers, and the administrative contexts in which M1006 appears. It also summarizes implications for quality measurement and documentation workflows.

Readers will learn what M1006 represents, how it is applied in clinical records, typical service settings, and areas where documentation gaps occur. The report provides benchmarks and policy-relevant context for coding completeness, notes common modifiers used alongside similar HCPCS Level II codes, and highlights where further clinical documentation may be required. Data constraints: where specific supporting data were not provided in the input, the text notes "Data not available in the input."

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1006HCPCS Level IIdocumentationoutpatient assessmentquality measurementdisease activityclinical codingbilling complianceambulatory care

Billing Code Overview

HCPCS Level II code M1006 indicates Disease activity not assessed, reason not given. This code captures encounters where a clinician documents that a patient’s disease activity was not evaluated, without providing a specific reason for the omission.

Service type: Assessment documentation omission
Typical site of service: Outpatient clinical visit or ambulatory care setting where disease activity assessment would ordinarily be expected

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient with a known chronic autoimmune rheumatologic condition such as rheumatoid arthritis presents for a routine disease-management visit. The clinician documents that a formal disease activity assessment (for example, Disease Activity Score [DAS28], Clinical Disease Activity Index [CDAI], or routine joint count and patient global assessment) was not performed and provides no reason in the medical record. The visit occurs in an outpatient clinic, typically a rheumatology office or specialty infusion center, where disease activity monitoring is expected as part of ongoing management. The clinical workflow begins with intake and medication reconciliation, proceeds to symptom review and focused physical exam, and would ordinarily include a standardized disease activity score; however, the clinician documents only medication adjustments, symptom report, and plan without documenting a disease activity metric or rationale for omitting it. Billing staff assign the HCPCS Level II code M1006 to indicate that disease activity was not assessed and no reason was given in the record. This code is used for encounters where disease activity measurement is an expected element of care but is absent from documentation, rather than for acute visits where such assessment would be inappropriate.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when a service is significantly greater than normally required; apply if documentation supports markedly increased work beyond the usual visit associated with .

HCPCS Level II M1043: ODI Not Measured at One-Year Postoperative

HCPCS-M1052-POSTOPERATIVE-LEG-PAIN-NO-VAS-OR-NUMERIC-MEASUREMENT

HCPCS Level II M1052: Postoperative Leg Pain, No VAS/Numeric Measurement

HCPCS-M1035-PHASED-OUT-MAT-BEFORE-180-DAYS-CONTINUOUS-TREATMENT

HCPCS Level II M1035: Adults Phased Out of MAT Before 180 Days

HCPCS-M1039-LUMBAR-SPINE-INFECTION-PROCEDURE

HCPCS Level II M1039: Lumbar Spine Region Infection at Procedure Time

HCPCS-M1044-OSWESTRY-DISABILITY-INDEX-PRE-AND-POST-OP-ASSESSMENT

HCPCS M1044: Oswestry Disability Index Pre- and Postoperative Assessment

HCPCS-M1010-DISCHARGE-EPISODE-OF-CARE-DOCUMENTED

HCPCS Level II M1010: Discharge of Episode of Care Documented

HCPCS-M1007-OUTPATIENT-RA-ASSESSMENT-OVER-50-PERCENT-ENCOUNTERS

HCPCS M1007: Outpatient Rheumatoid Arthritis Encounter Assessment >=50%

HCPCS-M1067-HOSPICE-SERVICES-MEASUREMENT-PERIOD

HCPCS Level II M1067: Hospice Services During Measurement Period

HCPCS-M1070-PATIENT-NOT-SCREENED-FALL-RISK

HCPCS Level II M1070: Patient Not Screened for Future Fall Risk

HCPCS-M1011-DISCHARGE-EPISODE-OF-CARE-DOCUMENTATION

HCPCS M1011: Discharge/Discontinuation of Episode of Care, Documented

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M1006

Taxonomy Code	Specialty	Notes
`207R00000X`	Rheumatology	Primary specialty responsible for disease activity assessment in autoimmune inflammatory conditions.
`207LP2900X`	Allergy & Immunology	Manages autoimmune and inflammatory disease care where activity assessment may be relevant.
`2084P0800X`	Internal Medicine	Often provides longitudinal care and may document disease activity assessments.
`363LP0800X`	Nurse Practitioner	Advanced practice providers who perform visits and document assessments in specialty clinics.
`207K00000X`	Clinical Immunology	Specialists who may manage complex inflammatory disorders and document activity measurements.

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

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 visit level during which disease activity assessment is expected; `M1006` indicates the activity assessment was not documented for such a visit.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Higher-complexity visit where standardized disease activity scoring is often performed; omission is captured by `M1006` when not documented.
`99204`	Office or other outpatient visit for the evaluation and management of a new patient, typically 45 minutes	New patient visits in rheumatology often include baseline disease activity measures; absence may be reported with `M1006`.
`99406`	Smoking and tobacco-use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Example of ancillary counseling often documented during visits; absence of disease activity assessment remains reportable with `M1006`.
`96372`	Therapeutic, prophylactic, or diagnostic injection (specified substance)	Procedures such as intra-articular injections often occur in the same encounter; disease activity assessment omission during these procedural visits is reported with `M1006` when appropriate.

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