Summary & Overview
HCPCS M1026: Patients in Hospice During Performance Period
HCPCS Level II code M1026 is a designation for patients who were in hospice at any time during the performance period. The code is used in reporting and quality measurement contexts to identify hospice status and ensure services and measures account for end-of-life care. Nationally, accurate capture of hospice status affects quality measurement, care coordination, and claims processing where hospice eligibility or exclusions are relevant.
Key payers addressed in this publication include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The discussion covers payer-specific coverage patterns and how hospice status is treated in measurement populations for these large commercial and federal payers.
Readers will find a concise description of the code’s clinical intent and service context, comparisons of common payer handling, and reference information relevant to billing and reporting workflows. The publication summarizes benchmarks where available, highlights relevant policy and reporting considerations at the national level, and provides clinical context about when and where M1026 is applied. Data not available in the input will be noted where applicable.
Billing Code Overview
HCPCS Level II code M1026 indicates patients who were in hospice at any time during the performance period. This code is used to identify and flag patient status related to hospice care during a specified measurement or reporting period.
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Service type: Hospice status tracking and reporting
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Typical site of service: Hospice settings, home hospice, inpatient hospice units, or any setting where hospice status is documented during the performance period
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult with a terminal illness (for example, advanced metastatic cancer, end-stage congestive heart failure, or late-stage chronic obstructive pulmonary disease) who was enrolled in hospice care at any point during the reporting or performance period. The patient may receive episodic inpatient hospice care, routine home hospice services, or continuous home care. Clinical workflow: hospice enrollment is documented in the medical record by the hospice physician or authorized representative, including the terminal diagnosis, prognosis (typically six months or less if the disease follows its usual course), and the plan of care. Nursing, social work, and chaplain notes document services delivered. When quality reporting or claims require identification of patients who were in hospice during the performance period, billing staff or quality analysts query records and flags using the hospice enrollment documentation and the hospice benefit dates. The hospice status is reported using the HCPCS Level II code M1026 to indicate the patient was in hospice at any time during the performance period. This is applied across care settings where hospice services were provided or documented, such as home, hospice inpatient unit, or hospital when hospice care was active.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When work required is substantially greater than typical for the billed service due to complexity of caring for a patient on hospice, if applicable to an accompanying CPT code. |