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

Summary & Overview

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

HCPCS Level II code M1007 documents that at least 50% of a patient’s outpatient rheumatoid arthritis (RA) encounters were assessed. This process measure captures the extent to which RA patients receive structured assessment during ambulatory visits, supporting quality monitoring and care coordination across outpatient practices. Nationally, documenting assessment rates for chronic inflammatory conditions like RA matters for quality reporting, value-based payment arrangements, and clinical program tracking.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of what the code represents, common service settings, and the policy and billing context in which the code is used. The publication outlines benchmarks and expected use cases for reporting RA encounter assessment rates, summarizes payer coverage considerations, and provides clinical context about why monitoring assessment frequency is relevant to patient management and quality measurement. Data not available in the input.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1007HCPCS Level IIrheumatoid arthritisoutpatient assessmentquality measureambulatory careclinical monitoringprocess measurevalue-based care

Billing Code Overview

HCPCS Level II code M1007 indicates that 50% or more of a patient's outpatient rheumatoid arthritis (RA) encounters were assessed. The service represented by this code is an outpatient clinical assessment specifically focused on monitoring the proportion of RA encounters that received formal assessment during a reporting period. Typical site of service is outpatient clinic or ambulatory care setting, where ongoing RA management and routine follow-up visits occur.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient with established rheumatoid arthritis (RA) attends an outpatient rheumatology clinic for routine disease activity assessment. The billing code M1007 documents that at least 50% of the patient’s outpatient RA encounters have been assessed for disease activity during a defined reporting period. Typical workflow: appointment check-in and vitals, targeted history for joint symptoms and functional status, physical exam focusing on joint counts, administration of validated disease activity measures (for example CDAI or RAPID3), medication reconciliation including DMARDs/biologics and adverse effects, documentation of treatment changes or escalation, and scheduling of follow-up. Clinical staff may collect patient-reported outcomes and enter scores into the electronic health record; the provider reviews scores, documents interpretation, and codes M1007 when cumulative encounter-level assessments reach the ≥50% threshold for the patient’s outpatient RA visits during the measurement period.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when services require substantially greater work than typical for the visit due to complexity of assessment or documentation for RA management.

Related Codes

HCPCS-M1068-NON-AMBULATORY-ADULT-CARE

HCPCS Level II M1068: Adults Who Are Not Ambulatory

HCPCS-M1024-ADOLESCENT-DEPRESSION-NONREMISSION-6-MONTHS

HCPCS M1024: Adolescent Depression Nonremission at Six Months

HCPCS-M1034-180-DAYS-OPIOID-USE-DISORDER-PHARMACOTHERAPY-CONTINUITY

HCPCS M1034: 180-Day Continuous Pharmacotherapy for Opioid Use Disorder

HCPCS-M1026-HOSPICE-STATUS-ANY-TIME-DURING-PERFORMANCE-PERIOD

HCPCS M1026: Patients in Hospice During Performance Period

HCPCS-M1033-PHARMACOTHERAPY-INITIATION-OPIOID-USE-DISORDER

HCPCS Level II M1033: Pharmacotherapy Initiation for Opioid Use Disorder

HCPCS-M1060-PATIENT-DIED-PRIOR-TO-PERFORMANCE-PERIOD

HCPCS M1060: Patient Died Prior to End of Performance Period

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

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

HCPCS-M1008-OUTPATIENT-RA-ENCOUNTER-ASSESSMENT-LESS-THAN-50-PERCENT

HCPCS M1008: Outpatient Rheumatoid Arthritis Encounter Assessment (<50%)

HCPCS-M1063-HIGH-DOSE-IMMUNOSUPPRESSIVE-THERAPY

HCPCS Level II M1063: High-Dose Immunosuppressive Therapy

HCPCS-M1037-LUMBAR-SPINE-CANCER-AT-PROCEDURE

HCPCS Level II M1037: Lumbar Spine Cancer Present at Procedure

Showing 1–10 of 67

Taxonomy Code	Specialty	Notes
`207RP0000X`	Rheumatology	Primary specialty performing RA disease activity assessments and management.
`207L00000X`	Internal Medicine	Internists frequently manage RA and perform outpatient disease activity assessments.
`208000000X`	Family Medicine	Family physicians may manage stable RA patients and document routine assessments.
`363LP0808X`	Nurse Practitioner	NPs commonly perform validated outcome measures and medication management in outpatient clinics.
`367500000X`	Physician Assistant	PAs support rheumatology clinics, perform joint counts, and document treatment decisions.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M05.79`	Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or system involvement	Representative seropositive RA code commonly associated with disease activity assessments captured by `M1007`.
`M06.9`	Rheumatoid arthritis, unspecified	Used when specific serologic status is not documented; relevant to routine monitoring and encounter-based assessments.
`M05.89`	Rheumatoid arthritis with rheumatoid factor of other multiple sites with organ or system involvement	Used when RA has extra-articular involvement; disease activity assessment is important to guide systemic therapy.
`M06.0`	Rheumatoid arthritis with involvement of other specified joints	Captures RA affecting specified joint groups and necessitates regular activity assessment.
`Z79.899`	Other long term (current) drug therapy	Indicates chronic use of immunosuppressive agents or DMARDs; relevant when documenting medication management during RA encounters.

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 E/M code used for routine RA follow-up visits during which disease activity assessment contributing to `M1007` is performed.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Counseling codes such as this may be reported when counseling is delivered during the RA visit but are ancillary to the disease activity assessment.
`93000`	Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report	Performed before initiation of certain RA therapies (e.g., some anti-arrhythmic or biologic pre-screening) as part of comprehensive visit workflows.
`96372`	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular	Used when corticosteroid or biologic injections are administered during the outpatient visit alongside disease activity assessment.
`87070`	Culture, bacterial; any other source except urine, blood, or stool, aerobic, bacterial; quantitative, colony count	Laboratory codes like this may be ordered for infection evaluation prior to immunosuppressive therapy initiation; part of the pre-treatment workup during RA management.