M1211 (HCPCS) Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1211: Most Recent Glycemic Status Assessment >9.0%

HCPCS Level II code M1211 denotes a documented most recent glycemic status assessment (hemoglobin A1c or glucose management indicator) with a value greater than 9.0%. This indicator identifies patients with poor glycemic control and is relevant to quality measurement, chronic disease management workflows, and clinical reporting nationwide. Its use can affect population health monitoring and care coordination for people with diabetes.

Key payers included in this overview are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what the code represents, its clinical context, and typical sites of service. The publication summarizes benchmarking considerations and policy-relevant implications for payers and providers, including how M1211 is used in reporting glycemic control and quality measurement frameworks.

The report provides national context rather than state-specific guidance and outlines what to expect in payer coverage patterns and administrative handling of lab-based glycemic indicators. Data not available in the input for associated taxonomies, ICD-10 diagnoses, or related codes is noted. The aim is to clarify the clinical meaning of M1211, the service contexts where it appears, and the operational uses payers and provider organizations apply for patients with A1c or GMI values above 9.0%.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1211HCPCS Level IIglycemic assessmenthemoglobin A1cglucose management indicatorquality measurementdiabetes management

Billing Code Overview

HCPCS Level II code M1211 indicates a patient's most recent glycemic status assessment (hemoglobin A1c or glucose management indicator) with a level greater than 9.0%. This code is used to denote a documented lab result that reflects poor glycemic control.

Service type: Glycemic status assessment reporting

Typical site of service: Outpatient clinics, primary care settings, endocrinology clinics, and laboratory reporting contexts

Data not available in the input for additional fields such as associated taxonomies, ICD-10 diagnoses, or related codes.

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient with long-standing type 2 diabetes mellitus is seen in a primary care clinic for routine diabetes management. The clinician reviews the most recent glycemic assessment and documents an HbA1c of 9.8% (or a continuous glucose monitoring-derived Glucose Management Indicator >9.0%). The visit includes medication review, assessment of adherence, evaluation for acute complications (hypoglycemia, hyperglycemia), and discussion of intensification of the diabetes regimen or referral to endocrinology. The workflow: order or obtain point-of-care or laboratory HbA1c (or GMI from CGM download), review results in the chart, document numerical value and that it exceeds the threshold >9.0%, reconcile medications, document patient counseling and any plan (medication change, education, referral) in the electronic health record, and select billing code M1211 to indicate most recent glycemic status assessment > 9.0%. Typical sites of service include outpatient primary care clinics, endocrinology clinics, community health centers, and telehealth visits when recent lab or CGM data are available. Typical patient scenario includes poor glycemic control despite therapy, missed appointments, or barriers to adherence requiring intensified management or specialist referral.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when documentation supports substantially greater work than typical for the visit associated with managing markedly uncontrolled diabetes and complex decision-making.

HCPCS M1423: Optimal Care for Urologic Conditions, MIPS Value Pathway

HCPCS-M1323-POST-INJECTION-IOP-SCREENING-PLAN-OF-CARE

HCPCS M1323: Post-Injection IOP Screening and Plan of Care

HCPCS-M1458-PATIENT-DIED-PERFORMANCE-PERIOD

HCPCS M1458: Patient Died Prior to End of Performance Period

HCPCS-M1268-KIDNEY-KIDNEY-PANCREAS-WAITLIST-ACTIVE-STATUS

HCPCS M1268: Kidney or Kidney–Pancreas Transplant Waitlist Active Status

HCPCS-M1407-PATIENT-DEATH-DURING-FOLLOW-UP

HCPCS Level II M1407: Patients Who Died During Follow-Up

HCPCS-M1184-DOCUMENTATION-MEDICAL-REASON-NO-CORTICOSTEROID-OR-IMMUNOSUPPRESSANT

HCPCS M1184: Documentation of Medical Reason for Not Prescribing Corticosteroid/Immunosuppressant

HCPCS-M1263-HOSPICE-DIALYSIS-INITIATION-EVALUATION

HCPCS M1263: Hospice Patient Evaluation at Dialysis Initiation

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

HCPCS M1445: Postpartum Care Visit, Up to 12 Weeks

HCPCS-LEVEL-II-M1503-VASCULAR-SURGERY-MIPS-VALUE-PATHWAY

HCPCS Level II M1503: Vascular Surgery MIPS Value Pathway

HCPCS-M1222-GLAUCOMA-PLAN-OF-CARE-NOT-DOCUMENTED

HCPCS M1222: Glaucoma Plan of Care Not Documented

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Common primary care specialty managing patients with elevated HbA1c and billing related outpatient diabetes services.
`207R00000X`	Internal Medicine	Internists frequently manage complex diabetes and document elevated glycemic measures.
`207RE0101X`	Endocrinology	Specialists who manage intensified therapy, insulin initiation, and CGM interpretation for high HbA1c/GMI values.
`363L00000X`	Nurse Practitioner	Advanced practice clinicians providing diabetes management and medication adjustments in outpatient settings.
`163W00000X`	Physician Assistant	Midlevel providers who manage routine and complex diabetes care under supervising physicians.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E11.65`	Type 2 diabetes mellitus with hyperglycemia	Directly indicates poor glycemic control and is commonly associated with HbA1c > 9.0%.
`E11.9`	Type 2 diabetes mellitus without complications	Used for patients with diabetes where specific complications are not documented; glycemic monitoring is routine.
`E10.65`	Type 1 diabetes mellitus with hyperglycemia	Type 1 diabetes patients with elevated HbA1c/GMI fit the criteria for `M1211`.
`R73.9`	Hyperglycemia, unspecified	Used when hyperglycemia is identified but diabetes type or complications are not yet specified.
`Z79.4`	Long term (current) use of insulin	Relevant when elevated HbA1c occurs despite insulin therapy and therapy review or adjustment is required.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`83036`	Hemoglobin; glycosylated (A1c)	Laboratory test that yields the HbA1c value which determines whether `M1211` criteria (>9.0%) are met.
`82962`	Glucose, blood by glucose monitoring device(s) cleared by FDA for home use	Point-of-care or patient self-monitoring data that may support assessment; CGM-derived GMI calculations often accompany office review.
`95250`	Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 7 days; interpretation and report by physician or other qualified health care professional	CGM application and interpretation that can generate GMI used to determine `M1211` status.
`95251`	Analysis, interpretation, and report of CGM data (sensor readings) completed by a physician or other qualified health care professional, each 30 days	Used when CGM data are reviewed and a GMI reported, supporting billing of `M1211`.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Counseling that may be provided during the visit as part of comprehensive diabetes management for patients with elevated HbA1c.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M visit code used for evaluation and management during which the HbA1c/GMI result >9.0% is reviewed and documented; `M1211` is reported specifically for the glycemic status assessment.

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