M1243 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1243: Patient-Reported Feeling Heard and Understood

HCPCS Level II code M1243 captures a patient-reported response indicating the patient did not select “completely true” when asked if they felt heard and understood by their provider and care team. As a patient experience measure, this code documents communication and relational aspects of care that increasingly inform quality reporting, value-based contracting, and patient-centered improvement efforts nationwide. Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will learn what HCPCS Level II code M1243 represents, the clinical and administrative contexts where it is used, and the national relevance for quality measurement and reporting. The publication provides benchmarks and comparative context where available, notes policy and coding considerations affecting use in payer programs, and explains typical service settings for capture. Data not available in the input is clearly noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1243HCPCS Level IIpatient experiencecommunicationoutpatientquality measurementpatient-reported outcomescare team communicationexperience metric

Billing Code Overview

HCPCS Level II code M1243 indicates that a patient provided a response other than "completely true" to the question assessing whether they felt heard and understood by the provider and team. This measure reflects a patient-reported experience about communication and interpersonal aspects of care.

Service type: Patient-reported experience/communication assessment
Typical site of service: Ambulatory care settings and other outpatient encounters where patient experience surveys or point-of-care patient-reported measures are collected

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient completes an outpatient experience survey after a primary care or specialty clinic visit and reports any response other than "completely true" to the question asking whether they felt heard and understood by the provider and care team. Typical workflow: at check-in or via an electronic patient-reported outcome platform, the patient receives a brief satisfaction questionnaire. Staff or the electronic system records the response. If the response indicates less-than-complete agreement, the clinic documents the result in the medical record, may trigger a patient experience review or service recovery workflow, and the visit is coded with billing code M1243 to capture the patient-reported experience measure. Typical sites of service include ambulatory primary care clinics, specialty outpatient clinics (such as cardiology, orthopedics, or behavioral health), and community health centers. Typical patient scenario: a 58-year-old patient presents for routine chronic disease management; after the visit the patient selects "somewhat true" on the item about feeling heard, the nurse documents the survey response, and the clinic uses M1243 to report the patient-reported outcome for quality measurement and performance reporting.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services

HCPCS M1485: HCV No Sustained Virological Response

HCPCS-M1463-POST-TREATMENT-FOLLOW-UP-CARE-COORDINATION

HCPCS Level II M1463: Documentation of Post-Treatment Follow-Up Attempts

HCPCS-M1473-ASSESSMENT-IMPACTING-FUNCTIONAL-MEASURE-VALIDITY

HCPCS M1473: Factors Affecting Validity of Functional/Cognitive Assessments

HCPCS-M1360-C-SSRS-SUICIDAL-IDEATION-BEHAVIOR-ASSESSMENT

HCPCS M1360: C-SSRS Suicidal Ideation and Behavior Assessment

HCPCS-LEVEL-II-M1356-PATIENTS-WHO-DIED-DURING-MEASUREMENT-PERIOD

HCPCS Level II M1356: Patients Who Died During the Measurement Period

HCPCS-M1182-IBD-INELIGIBILITY-PRE-EXISTING-INFLAMMATORY-BOWEL-DISEASE

HCPCS M1182: Ineligibility Due to Pre-existing Inflammatory Bowel Disease

HCPCS-M1412-METASTATIC-NSCLC-TARGETED-THERAPY-EGFR-ALK-ROS1-BRAF-NTRK-MET-RET

HCPCS M1412: Metastatic NSCLC with Targetable Genomic Alterations

HCPCS-M1413-PD-L1-POSITIVE-PRE-FIRST-LINE-IMMUNOTHERAPY

HCPCS M1413: PD-L1 Positive Prior to First-Line Immune Checkpoint Inhibitor Therapy

HCPCS-M1347-PAM-SCORE-IMPROVEMENT-4-12-MONTHS

HCPCS M1347: PAM Score Improvement Over 4–12 Months

HCPCS-M1358-PERSISTENT-SUICIDAL-IDEATION-FOLLOW-UP

HCPCS M1358: Persistent Suicidal Ideation or Behavior on Follow-Up

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care providers commonly document patient experience measures such as `M1243`.
`207R00000X`	Internal Medicine	Internists managing chronic conditions frequently capture patient-reported experience data.
`207K00000X`	Pediatric Medicine	Pediatricians document parent or adolescent patient experience responses when applicable.
`208D00000X`	Psychiatry & Neurology	Behavioral health providers may collect and bill patient experience measures after visits.
`261QM0800X`	Nurse Practitioner	Nurse practitioners in outpatient settings commonly collect and document patient satisfaction items.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z71.89`	Other specified counseling	Relevant when the visit included counseling components that affect patient perception of being heard.
`Z00.00`	Encounter for general adult medical examination without abnormal findings	Preventive and routine exams commonly include patient experience surveys.
`F41.9`	Anxiety disorder, unspecified	Behavioral health symptoms where patient perception of being understood impacts care and is measured.
`I10`	Essential (primary) hypertension	Chronic disease management visits where patient-provider communication is assessed by `M1243`.
`E11.9`	Type 2 diabetes mellitus without complications	Chronic care visits where patient experience measures are collected for quality and self-management support.
`Z13.9`	Encounter for screening, unspecified	Screening encounters that may include patient satisfaction items.
`R45.89`	Other symptoms and signs involving emotional state	Symptoms where the patient's sense of being heard is clinically relevant to management decisions.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common primary E/M visit during which the patient experience question is administered and documented.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Example of counseling service that may extend visit time and influence patient perception captured by `M1243`.
`99396`	Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; 40-64 years	Preventive visits where patient experience measures are routinely collected for quality reporting.
`90834`	Psychotherapy, 45 minutes with patient when performed with an E/M visit	Behavioral health visits where feeling heard and understood is a core component and patient-reported measures are used.
`96127`	Brief emotional/behavioral assessment (e.g., screening) with scoring and documentation, per standardized instrument	Short patient-reported instruments administered in clinic that may be bundled with satisfaction measures like `M1243`.

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