HCPCS M1191: Hospice Services During Measurement Period - OpenPayer

Summary & Overview

HCPCS M1191: Hospice Services During Measurement Period

HCPCS Level II code M1191 denotes hospice services provided to a patient at any time during the measurement period, capturing whether hospice care was delivered within a defined reporting window. This code matters nationally because hospice utilization is a key quality and utilization measure for end-of-life care programs, payment models, and care coordination efforts across public and private payers. Payors commonly included in national analyses are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn what M1191 represents clinically and operationally, how it is used in measurement and reporting, and which payers commonly include it in claims and quality workflows. The publication summarizes benchmarks where available, clarifies typical sites of service for hospice reporting, and outlines the clinical context in which hospice capture is relevant for quality measurement and utilization management. Where specific data points, taxonomies, or related diagnosis lists are not provided in the input, the text notes that those elements are not available. This summary is aimed at clinicians, billing professionals, policy analysts, and payer administrators seeking a concise reference to the purpose and scope of M1191 in national billing and quality programs.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1191HCPCS Level IIhospiceend-of-life carequality measurementclaims codingservice linecare coordination

Billing Code Overview

HCPCS Level II code M1191 represents hospice services provided to a patient any time during the measurement period. The service type is hospice care, and the typical site of service is hospice setting or any site where hospice services are delivered, including inpatient hospice facilities, hospice inpatient units, nursing facilities, and patient residences.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with a life-limiting illness (for example, advanced metastatic cancer, end-stage heart failure, severe chronic obstructive pulmonary disease, or advanced neurodegenerative disease) who is enrolled in a hospice program and receives hospice services at any time during the measurement period. The clinical workflow begins with an interdisciplinary hospice assessment by the hospice medical director or attending physician, nurse assessment, and documentation of hospice election, goals of care, and advance directives. Ongoing care may include periodic home visits by hospice nurses, hospice aide visits, social work and spiritual care visits, medication management, symptom control, and coordination with the patient’s primary care clinician. Hospice services are provided in settings such as the patient’s residence, assisted living facility, nursing facility, or inpatient hospice unit. Billing occurs when hospice services are furnished during the measurement period and reported using the hospice-specific HCPCS Level II code M1191 to indicate that hospice services were provided to the patient during that timeframe.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	When additional physician work or time was significantly greater than usual for a documented hospice service-related procedure or visit.

HCPCS M1444: Delivery Before 39 Weeks of Gestation

HCPCS-M1265-CMS-MEDICAL-EVIDENCE-FORM-2728-INITIAL

HCPCS M1265: CMS Medical Evidence Form 2728, Initial Completion

HCPCS-M1464-FOLLOW-UP-DOCUMENTATION-DEFICIENCY

HCPCS Level II M1464: Missing Documentation of Follow-Up Attempts

HCPCS-M1419-NOT-UP-TO-DATE-COVID-19-VACCINATION-STATUS

HCPCS Level II M1419: Not Up to Date on COVID-19 Vaccinations

HCPCS-M1220-DILATED-RETINAL-EXAM-RETINOPATHY

HCPCS M1220: Dilated Retinal Exam with Interpretation for Retinopathy

HCPCS-M1385-DOCUMENTATION-PAM-FOLLOW-UP-NONCOMPLETION

HCPCS M1385: Documentation of Reasons for Missed Second PAM Survey

HCPCS-LEVEL-II-M1326-HYPOTONY-EVALUATION-MANAGEMENT

HCPCS Level II M1326: Patients with Diagnosis of Hypotony

HCPCS-M1288-DOCUMENTED-REASON-NOT-SCREENING-HIGH-BLOOD-PRESSURE

HCPCS M1288: Documented Reason for Not Screening or Recommending Follow-Up for High Blood Pressure

HCPCS-M1272-KIDNEY-KIDNEY-PANCREAS-TRANSPLANT-WAITLIST-MEMBERSHIP

HCPCS M1272: Kidney or Kidney-Pancreas Transplant Waitlist Membership

HCPCS-M1190-KIDNEY-HEALTH-EVALUATION-DOCUMENTATION-MISSING

HCPCS Level II M1190: Documentation Missing for Kidney Health Evaluation

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Taxonomy Code	Specialty	Notes
353N00000X	Hospice and Palliative Medicine	Primary specialty for clinicians providing hospice services and medical direction.
207Q00000X	Family Medicine	Common attending clinicians coordinating hospice care for community-based patients.
208D00000X	Internal Medicine	Hospital-based or outpatient internists involved in hospice eligibility and management.
207R00000X	Geriatric Medicine	Specialists who commonly manage end-of-life care needs in older adults.
2084P0800X	Palliative Medicine (non-physician)	Advanced practice providers focused on symptom management within hospice teams.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z51.5`	Encounter for palliative care	Commonly used to denote palliative-focused care and often appears in hospice documentation when focusing on comfort measures.
`C80.1`	Malignant (primary) neoplasm, unspecified site — metastatic disease	Advanced cancer with metastasis is a frequent primary diagnosis leading to hospice enrollment.
`I50.9`	Heart failure, unspecified	End-stage heart failure is a common non-malignant diagnosis prompting hospice services for symptom management.
`J96.00`	Acute respiratory failure, unspecified whether with hypoxia or hypercapnia	Respiratory failure in progressive lung disease may lead to hospice transition for comfort care.
`G30.9`	Alzheimer disease, unspecified	Advanced dementia with functional decline is a standard hospice-eligible condition.
`N18.6`	End stage renal disease	ESRD patients may elect hospice for comfort-focused care when disease is terminal.
`F03.90`	Unspecified dementia without behavioral disturbance	Cognitive decline and functional impairment often support hospice eligibility and care planning.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99497`	Advance care planning including the explanation and discussion of advance directives, by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate	Often performed before or during hospice enrollment to document goals of care and advance directives that inform hospice services.
`99341`	Home visit for new patient, typically 20 minutes face-to-face with the patient and/or family	Represents an initial home hospice visit by a physician when hospice services are initiated in the patient’s residence.
`99347`	Home visit for established patient, typically 20 minutes face-to-face with the patient and/or family	Used for routine follow-up home visits by physicians after hospice enrollment.
`99324`	Domiciliary or rest home visit for the evaluation and management of a new patient, typically 30 minutes	Applicable when hospice services are provided in an assisted living or residential facility setting.
`99406`	Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes	Example of supportive counseling services that may occur as part of hospice psychosocial care (used when clinically relevant).
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory)	Used by hospice teams to assess symptoms such as depression or anxiety as part of comprehensive hospice care.

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