Summary & Overview
HCPCS Level II M1146: Ongoing Care Not Clinically Indicated, Home Program/Referral
HCPCS Level II code M1146 represents documentation that ongoing therapeutic care is not clinically indicated because the patient requires a home program only, a referral to another provider or facility, or a consultation only. Nationally, this code matters because it documents transitions in care plans where active treatment is halted in favor of non-procedural alternatives, affecting utilization reporting and appropriate billing for discontinued services. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn the clinical context in which M1146 is used, typical sites of service, common modifiers associated with billing when applicable, and how payers commonly address claims with this designation. The publication reviews how M1146 is documented in the medical record, summarizes implications for service-lines that commonly use the code (outpatient therapy and rehabilitation), and highlights considerations for claims processing and denial drivers. Data not available in the input is noted where relevant, and the guide focuses on national policy and billing practice context rather than state-specific rules.
Billing Code Overview
HCPCS Level II code M1146 denotes ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record. This code describes situations in which continued therapeutic services were considered unnecessary by the treating clinician because the appropriate plan of care consisted of a home exercise or home program, a referral for a different service or setting, or only a consultation rather than continued procedural care.
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Service type: Discontinued or non-indicated ongoing therapeutic care due to alternative plan (home program, referral, or consultation)
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Typical site of service: Ambulatory outpatient settings, therapy clinics, or other outpatient facilities where therapy services are provided and a decision is made to cease ongoing treatment in favor of a home program, referral, or consultation
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an outpatient physical therapy or rehabilitation visit where ongoing skilled therapeutic services are determined to be not clinically indicated because the patient requires only a home exercise program, referral to another provider or facility, or a single consultation only. For example, a 72-year-old patient with chronic low back pain attends a scheduled physical therapy follow-up. During evaluation the therapist documents that the patient demonstrates adequate self-management, no skilled therapeutic intervention is indicated, and a home exercise program with written instructions is provided. The therapist documents that continuing visits are unnecessary and that referral to primary care for medication review or to a pain clinic for injection consultation is appropriate. The clinical workflow includes evaluation, documentation of rationale for discontinuing skilled services, provision of home program instructions or referral documentation, and billing using M1146 to report ongoing care not clinically indicated because only a home program, referral, or consultation was needed.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When work required is substantially greater than typical for the service and documented accordingly |
23 | Unusual anesthesia | When general or regional anesthesia was medically necessary and not ordinarily used |
52 | Reduced services | When the service performed was partially reduced or eliminated and documented |
53 | Discontinued procedure | When the procedure was started but terminated due to extenuating circumstances |
54 | Surgical care only | When only the surgical portion of care is performed and postoperative care is transferred |
55 | Postoperative management only | When only postoperative management is furnished by the reporting provider |
56 | Preoperative management only | When only preoperative evaluation and management is furnished by the reporting provider |
62 | Two surgeons | When two surgeons work together as primary surgeons performing distinct parts of a procedure |
AS | Ambulatory surgical center service | When services are performed in an ambulatory surgical center setting |
CO | Occupational therapy modifier (specific payer use) | When denoting occupational therapy services per payer guidance |
CQ | Service provided in a residence by civilian provider under TRICARE | When applicable for TRICARE-paid home-based services |
FX | Fiscal intermediary use (payer-specific) | When required by specific intermediary billing rules |
QK | Medical direction of two, three, or four assistants at surgery | When the physician medically directs assistants at surgery |
QX | Certified registered nurse anesthetist (CRNA) service with medical direction | When CRNA provides anesthesia and the anesthesiologist medically directs |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
225100000X | Physical Therapist | Primary clinicians who evaluate and provide therapy and home programs |
225200000X | Occupational Therapist | Provides functional home programs and ADL-focused interventions |
208D00000X | Physical Medicine & Rehabilitation Physician | Oversees rehabilitation plans and consultation decisions |
207Q00000X | Family Medicine Physician | May refer patients to therapy or receive return recommendations |
207L00000X | Orthopedic Surgeon | Referral source for consultation when procedural intervention is considered |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
| Data not available in the input. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
97161 | Physical therapy evaluation, low complexity | Initial PT evaluation that may precede a determination that ongoing skilled care is not indicated |
97110 | Therapeutic exercises to develop strength, endurance, range of motion and flexibility | Common skilled therapy intervention performed when ongoing care is indicated; absence of need for this supports M1146 use |
97140 | Manual therapy techniques (e.g., mobilization/manipulation) | Skilled hands-on treatment that, if not required, supports billing M1146 when only a home program is needed |
97530 | Therapeutic activities, direct (one-on-one) therapy | Functional activities provided when skilled intervention is required; not provided when M1146 is reported |
G0127 | Brief office visit for the evaluation and management of a patient requiring decision making (Medicare G-code example) | Used for brief consultative encounters that may result in referral only; often paired administratively with documentation leading to M1146 billing |