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    v1.0.30
    OpenPayerBilling CodesEpisode of CareHCPCS hcpcs-m1115-patient-self-discharge-interrupted-care
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    HCPCS Level II M1115: Patient Self-Discharged, Ongoing Care Not Possible

    HCPCS Level II code M1115 indicates that ongoing care was not possible because the patient self-discharged early (examples: financial or insurance reasons, transportation problems, or unknown reason); this code documents a service episode where planned follow-up or continued treatment could not be completed, typically classified as a care-termination event in outpatient or inpatient discharge records and used to capture the clinical circumstance when patients leave before completion of care, often recorded in hospital, emergency department, or clinic discharge workflows.

    For related coverage guidance, see recent payer policy updates: Adult Foster Care, Group Adult Foster Care Clinical Coverage Criteria, Home Health Care Payment Policy.

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient scenario involves an adult receiving outpatient behavioral health or medical treatment who discontinues care by leaving the facility before planned discharge or before scheduled treatments can be completed due to financial constraints, lack of transportation, or unknown reasons. For example, a 42-year-old patient admitted to an outpatient opioid use disorder clinic for medication management and counseling arrives for a scheduled visit, begins intake and medication counseling, but requests to leave early and declines further services citing inability to pay and lack of reliable transportation. The clinic documents the encounter, attempts to address barriers (financial counseling, scheduling assistance, and community resources), and records that ongoing care was not possible because the patient self-discharged early. Clinical workflow steps include triage/intake, initial assessment, initiation of planned services (medication, counseling, or observation), documentation of the patient-initiated early departure, attempted outreach and referral options, and closure of the episode of care with appropriate billing using code M1115 to indicate care was not completed due to self-discharge.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    99213Office or other outpatient visit for the evaluation and management of an established patient, moderate complexityOften used for the initial E/M visit that may be partially completed before the patient self-discharged; documents services rendered.
    99406Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutesExample of a counseling service that may be initiated but not completed due to early patient departure.
    90791Psychiatric diagnostic evaluation (without medical services)May be initiated during intake; if the patient self-discharges, M1115 documents that the planned evaluation could not be completed.
    99204Office or other outpatient visit for the evaluation and management of a new patient, moderate to high complexityUsed when a new patient appointment is started but terminated early by self-discharge; documents portion of evaluation performed.
    90837Psychotherapy, 60 minutes with patient and/or family memberRepresents a therapy session that could be interrupted or not completed because the patient left early; M1115 indicates ongoing care not possible.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    163W00000X
    2084P0800X
    207Q00000X
    363L00000X
    207L00000X
    261QM2800X
    363LX0106X
    283X00000X

    Related ICD-10-CM Codes

    20 rows

    ICD-10-CM CodeDescription
    E11.9Type 2 diabetes mellitus without complications
    E66.9Obesity, unspecified
    F10.20Alcohol dependence, uncomplicated
    F32.9Major depressive disorder, single episode, unspecified
    F41.9Anxiety disorder, unspecified
    G43.909Migraine, unspecified, not intractable, without status migrainosus
    I10Essential (primary) hypertension
    J18.9Pneumonia, unspecified organism
    J44.9Chronic obstructive pulmonary disease, unspecified
    K21.9Gastro-esophageal reflux disease without esophagitis

    Showing 1–10 of 20

    Related Payer Policy Updates

    Specialty: Home Health & Hospice1 / 2

    10 rows

    PolicyPayerEffective Date
    Adult Foster Carefallon_community_health_plan_inc2027-01-27
    Group Adult Foster Care Clinical Coverage Criteriafallon_community_health_plan_inc2027-01-01
    Home Health Care Payment Policyfallon_community_health_plan_inc2026-12-01
    Private Duty Nursing in the Home SettingAnthem2026-10-01
    Home Health, Skilled, and Custodial Care Services (for Nebraska Only)UnitedHealthcare2026-10-01
    Home Health, Skilled, and Custodial Care Services (for Tennessee Only)UnitedHealthcare2026-10-01
    Home Health, Skilled, and Custodial Care Services (for Kansas Only)UnitedHealthcare2026-09-01
    Private Duty Nursing Services (for Nebraska Only)UnitedHealthcare2026-09-01
    Home Health, Skilled, and Custodial Care Services (for New Jersey Only)UnitedHealthcare2026-09-01
    Home Health, Skilled, and Custodial Care Services (for Idaho Only)UnitedHealthcare2026-08-01

    Related Codes

    HCPCS-LEVEL-II-M1111-EPISODE-OF-CARE-INITIATION-DOCUMENTATION

    HCPCS M1111: Start of Episode of Care

    HCPCS-LEVEL-II-M1120-PATIENT-SELF-DISCHARGED-EARLY

    HCPCS Level II M1120: Ongoing Care Interrupted by Patient Self-Discharge

    HCPCS-M1106-START-OF-EPISODE-OF-CARE

    HCPCS Level II M1106: Start of Episode of Care Documentation

    HCPCS-M1107-DEGENERATIVE-NEUROLOGICAL-DIAGNOSIS-DOCUMENTATION

    HCPCS Level II M1107: Documentation of Degenerative Neurological Condition

    HCPCS-M1108-HOME-PROGRAM-REFERRAL-CONSULTATION-ONLY

    HCPCS Level II M1108: Ongoing Care Not Clinically Indicated

    HCPCS-M1109-ONGOING-CARE-INTERRUPTED-DUE-TO-EARLY-DISCHARGE

    HCPCS Level II M1109: Ongoing Care Interrupted by Hospitalization or Surgery

    HCPCS-M1110-EARLY-SELF-DISCHARGE-CARE-INTERRUPTED

    HCPCS Level II M1110: Ongoing Care Not Possible — Patient Self-Discharged

    HCPCS-M1112-DEGENERATIVE-NEUROLOGICAL-DIAGNOSIS-DOCUMENTATION

    HCPCS Level II M1112: Documentation of Degenerative Neurological Diagnosis

    HCPCS-M1113-ONGOING-CARE-NOT-CLINICALLY-INDICATED-HOME-PROGRAM-REFERRAL-CONSULTATION

    HCPCS Level II M1113: Ongoing Care Not Clinically Indicated

    HCPCS-M1114-CARE-DISCONTINUED-DUE-TO-HOSPITALIZATION-OR-SURGERY

    HCPCS M1114: Ongoing Care Interrupted by Hospitalization or Surgery

    Showing 1–10 of 37

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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