Summary & Overview
HCPCS Level II M1035: Adults Phased Out of MAT Before 180 Days
HCPCS Level II code M1035 indicates adults who are deliberately phased out of medication assisted treatment (MAT) prior to completing 180 days of continuous treatment. The code captures a specific clinical disposition — early, planned discontinuation of MAT — which can affect quality measurement, care continuity, and payment reporting. Nationally, recording early MAT phase-out is relevant to addiction-treatment monitoring, program evaluation, and payer policy design.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what M1035 represents, the likely service contexts where it is used, and how the code fits into clinical documentation and claims workflows. The publication outlines typical benchmarks and reporting considerations where available, summaries of payer coverage posture, and clinical context about MAT duration and discontinuation practices.
This summary addresses coding purpose and operational impact for clinicians, billers, and policy analysts seeking national-level orientation to M1035. Data not available in the input is identified where relevant.
Billing Code Overview
HCPCS Level II code M1035 identifies adults who are deliberately phased out of medication assisted treatment (MAT) prior to 180 days of continuous treatment. The code describes a care classification rather than a discrete procedure — it documents patients discontinued from MAT before the 180-day continuous-treatment milestone.
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Service type: Clinical care classification related to medication management and treatment discontinuation.
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Typical site of service: Behavioral health clinics, outpatient addiction treatment programs, primary care settings with MAT services, and other ambulatory facilities where MAT is delivered.
Clinical & Coding Specifications
Clinical Context
A typical patient is a 35-year-old adult who began medication-assisted treatment (MAT) for opioid use disorder with buprenorphine/naloxone five weeks ago in an outpatient addiction treatment clinic. During a scheduled follow-up, the treating clinician and patient agree to a deliberate, structured taper and discontinuation of MAT prior to reaching 180 days of continuous treatment because of medication intolerance and patient preference. The workflow includes documentation of informed consent for taper, a medically supervised dose reduction plan, enhanced monitoring visits (weekly or biweekly), coordination with behavioral health counseling, risk assessment for withdrawal and overdose, provision of naloxone and education, and a clear aftercare plan including relapse prevention strategies and rapid re-engagement pathways. Billing staff assign HCPCS Level II code M1035 to indicate the patient was deliberately phased out of MAT before 180 days, and attach clinically appropriate modifiers for unusual circumstances (for example, professional work modifiers or time-limited services). Typical sites of service are outpatient addiction treatment clinics, office-based opioid treatment programs, community mental health centers, and primary care practices with integrated behavioral health. The typical patient scenario involves frequent follow-up visits, medication management documentation, and coordination with ancillary services such as counseling, social work, and overdose-prevention education.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |