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

Summary & Overview

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

HCPCS Level II code M1052 documents that leg pain was not measured by the visual analog scale (VAS) or a numeric pain scale at the one-year postoperative interval (9 to 15 months). Nationally, this code captures gaps in standardized pain-assessment documentation during a key postoperative follow-up window and can affect quality measurement and reporting for surgical recovery and pain management programs.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. Readers will find a concise explanation of the code’s clinical context, typical service setting, and implications for documentation and quality measurement. The publication provides benchmark-oriented content and policy context relevant to postoperative surveillance programs, describes common scenarios where the code is applied, and outlines how the code is used in payer reporting and administrative workflows.

Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1052HCPCS Level IIpostoperative follow-uppain assessmentvisual analog scaleoutpatient clinicdocumentationquality measurementsurgical recovery

Billing Code Overview

HCPCS Level II code M1052 indicates that leg pain was not measured by the visual analog scale (VAS) or numeric pain scale at one year (9 to 15 months) postoperatively. This code documents the absence of a standardized pain score assessment for postoperative leg pain during the specified follow-up interval.

Service type: Postoperative pain assessment documentation (absence of standardized pain measurement)
Typical site of service: Outpatient follow-up visit or postoperative clinic visit within the 9- to 15-month postoperative window

Clinical & Coding Specifications

Clinical Context

A 62-year-old patient underwent lower extremity orthopedic surgery (e.g., total knee arthroplasty) and is seen in routine postoperative follow-up at one year (9–15 months). During the visit, the clinician documents wound healing, range of motion, neurovascular status, and patient-reported outcomes but omits a formal pain score. The visit occurs in an ambulatory orthopedic clinic. The coding note M1052 captures that leg pain was not measured by the visual analog scale (VAS) or numeric pain scale at one year postoperatively. Typical workflow: pre-visit chart review, focused physical exam of the operative limb, functional assessment, and completion of standardized outcome forms; pain assessment via VAS or numeric scale is expected to be recorded at the 12-month interval but was not documented in this encounter.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when additional work beyond usual is documented for the visit (e.g., complex medical decision-making during the 12-month follow-up).
`23`	Unusual anesthesia

HCPCS M1014: Discharge/Discontinuation of Episode of Care

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

HCPCS M1060: Patient Died Prior to End of Performance Period

HCPCS-M1006-DISEASE-ACTIVITY-NOT-ASSESSED

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

HCPCS-M1067-HOSPICE-SERVICES-MEASUREMENT-PERIOD

HCPCS Level II M1067: Hospice Services During Measurement Period

HCPCS-M1068-NON-AMBULATORY-ADULT-CARE

HCPCS Level II M1068: Adults Who Are Not Ambulatory

HCPCS-M1012-DISCHARGE-EPISODE-OF-CARE-DOCUMENTATION

HCPCS Level II M1012: Discharge/Discontinuation of Episode of Care

HCPCS-M1064-SHINGRIX-VACCINE-ADMINISTRATION-OR-DOCUMENTED-PRIOR-DOSE

HCPCS Level II M1064: Shingrix vaccine administered or previously received

HCPCS-M1043-OSWESTRY-DISABILITY-INDEX-NOT-MEASURED-1YR-POSTOP

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

HCPCS-M1061-PATIENT-PREGNANCY-ASSESSMENT-DOCUMENTATION

HCPCS Level II M1061: Patient Pregnancy

HCPCS-M1062-PATIENT-IMMUNOCOMPROMISED

HCPCS M1062: Patient Immunocompromised

Showing 1–10 of 67

Taxonomy Code	Specialty	Notes
`2080P0000X`	Orthopedic Surgery	Primary specialty managing postoperative lower-extremity orthopedic follow-up.
`207L00000X`	Physical Medicine & Rehabilitation	Specialists who perform functional outcome assessments and manage postoperative rehabilitation.
`207K00000X`	Family Medicine	Primary care clinicians who may document routine postoperative follow-up in some settings.
`367A0000X`	Pain Medicine	Clinicians focused on pain assessment and management when postoperative pain issues are raised.
`363LP0800X`	Physician Assistant	Common allied provider involved in clinic follow-up and documentation of pain scores.

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

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99024`	Postoperative follow-up visit, normally included in the global service, subsequent to the postoperative period	Often used for routine postoperative visits; documentation should include pain assessment such as VAS or numeric scale at the 12-month visit.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M level for a focused postoperative follow-up where pain score measurement is expected but may be omitted.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used when moderate complexity evaluation is performed at the one-year visit, often accompanying comprehensive documentation including pain scales.
`97110`	Therapeutic exercises to develop strength and endurance, range of motion and flexibility	Frequently provided as part of rehabilitation during follow-up visits where pain and function are assessed.
`99212`	Office or other outpatient visit for the evaluation and management of an established patient, typically 10 minutes	Used for brief postoperative checks; omission of a documented pain score may still occur at this level.

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