M1165 Hospice Services (HCPCS) Reimbursement | OpenPayer

Summary & Overview

HCPCS M1165: Hospice Services During Measurement Period

HCPCS Level II code M1165 indicates patients who used hospice services at any point during the measurement period. This status code is used in performance measurement and reporting to identify patients receiving hospice care and to inform care coordination, quality assessment, and population management efforts. Nationally, consistent capture of hospice status matters for accurate quality measurement, care transition tracking, and reimbursement alignment across settings.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical context, how hospice service encounters are represented, typical sites of service, and which payers commonly include this measure in reporting. The publication also outlines available benchmarks, discusses relevant policy and reporting implications, and highlights operational considerations for capturing hospice status in claims and quality data.

This summary provides a concise reference for clinicians, coders, and administrators seeking to understand the role of M1165 in national hospice measurement and reporting frameworks. Data not available in the input regarding associated taxonomies, ICD-10 diagnoses, and related codes is noted elsewhere in the full publication.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1165HCPCS Level IIhospiceend-of-life carequality measurementclaims reportingcare coordinationhospice services

Billing Code Overview

HCPCS Level II code M1165 describes patients who use hospice services any time during the measurement period. This code represents hospice enrollment status captured for quality measurement and reporting purposes.

Service type: Hospice services and end-of-life care coordination
Typical site of service: Hospice settings, including inpatient hospice facilities, hospice inpatient units within hospitals, hospice residence, and home hospice care

Clinical & Coding Specifications

Clinical Context

A patient receiving hospice services enrolls with a hospice provider during the measurement period for end-of-life symptom management and comfort-focused care. Typical patient: an 82-year-old with advanced metastatic lung cancer and progressive dyspnea, who elects hospice care and is admitted for symptom control, psychosocial support, and family counseling. The clinical workflow begins with hospice eligibility assessment and documentation of terminal prognosis, enrollment and consent, initiation of interdisciplinary care plan (nursing, social work, spiritual care, and physician oversight), medication management for pain and dyspnea, and regular visits to manage symptoms and goals of care. Encounters are documented in the hospice medical record; billing captures hospice utilization during the measurement period using billing code M1165 to indicate the patient received hospice services at any point in the reporting window. Typical sites of service include the patient’s residence, skilled nursing facility, inpatient hospice unit, or hospital when hospice services are provided. Care coordination with the patient’s primary physician and palliative specialists is documented in the plan of care and discharge/transfer notes as needed.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than typically required for hospice-related procedures or visits documented with supporting rationale and time.

HCPCS M1481: Hospice or Palliative Care or Deceased During Measurement Period

HCPCS-M1346-PAM-NO-NET-INCREASE-4-12-MONTHS

HCPCS Level II M1346: No Net PAM Score Increase (4–12 Months)

HCPCS-M1495-FALL-RISK-ASSESSMENT-CARE-PLAN

HCPCS Level II M1495: Fall Risk Assessment and Care Plan

HCPCS-M1257-CVD-RISK-ASSESSMENT-NOT-PERFORMED-OR-INCOMPLETE

HCPCS Level II M1257: CVD Risk Assessment Not Performed or Incomplete

HCPCS-M1285-MAMMOGRAPHY-RESULTS-NOT-DOCUMENTED-REVIEW

HCPCS Level II M1285: Mammography Results Not Documented and Reviewed

HCPCS-M1179-PNEUMOCOCCAL-VACCINE-NOT-RECEIVED-ADULT

HCPCS M1179: Adult Pneumococcal Vaccine Not Received

HCPCS-M1431-TELEHEALTH-ENCOUNTER

HCPCS Level II M1431: Telehealth Encounters

HCPCS-M1445-POSTPARTUM-CARE-VISIT-12-WEEKS

HCPCS M1445: Postpartum Care Visit, Up to 12 Weeks

HCPCS-M1225-IOP-REDUCTION-GREATER-THAN-EQUAL-20-PERCENT

HCPCS M1225: Intraocular Pressure Reduction ≥20%

HCPCS-M1408-GERMLINE-BRCA-TESTING-BEFORE-OVARIAN-CANCER-DIAGNOSIS

HCPCS M1408: Germline BRCA Testing Before Ovarian Cancer Diagnosis

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Taxonomy Code	Specialty	Notes
`251B00000X`	Hospice and Palliative Medicine Physician	Primary medical oversight and eligibility certification for hospice care.
`207R00000X`	Family Medicine Physician	Commonly provides hospice referrals, management, and ongoing primary care coordination.
`3336L0002X`	Registered Nurse	Nursing assessment, symptom management, and daily hospice care delivery.
`251S00000X`	Palliative Medicine Specialist	Consultation for complex symptom management and goals-of-care discussions.
`172500000X`	Social Worker	Psychosocial assessment, counseling, and care coordination for patients and families.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C34.90`	Malignant neoplasm of unspecified part of unspecified bronchus or lung	Common terminal diagnosis leading to hospice enrollment for symptom control and comfort care.
`I50.9`	Heart failure, unspecified	Advanced heart failure frequently results in hospice referral when disease is refractory to curative treatment.
`F03.90`	Unspecified dementia without behavioral disturbance	Dementia with progressive decline often leads to hospice care for comfort and caregiver support.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	End-stage COPD is a typical hospice diagnosis for dyspnea and palliation.
`N18.6`	End-stage renal disease	Patients with ESRD may elect hospice when dialysis is discontinued or focus shifts to comfort.
`G30.9`	Alzheimer's disease, unspecified	Advanced Alzheimer disease commonly aligns with hospice goals of care and palliation.
`C80.1`	Malignant (primary) of unspecified site, with metastasis	Metastatic cancer diagnoses are a frequent reason for hospice admission for symptom management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99341`	Home visit for the evaluation and management of a new patient, typically 15-30 minutes	May be used for hospice initial or follow-up home visits by physicians when evaluating or managing hospice patients in their residence.
`99324`	Skilled nursing facility (SNF) initial nursing facility care, per day, for the evaluation and management of a patient (note: historical series of SNF codes)	Used when hospice provides care in a skilled nursing facility; facility-specific E/M codes capture physician visits.
`99307`	Subsequent hospital care, per day, for the evaluation and management of established patient, low complexity	Used for inpatient hospice unit or hospital encounters while patient is under hospice care.
`99304`	Initial nursing facility care, per day, comprehensive initial visit	Used for initial comprehensive evaluation in a nursing facility when a patient enrolls in hospice residing in that facility.
`G0182`	Physician certification of terminal illness (initial) (Medicare)	Used to document and bill the physician certification required for Medicare hospice eligibility determination; often part of the hospice enrollment workflow.

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