M1253 HCPCS: Reimbursement & Policy Benchmarks

HCPCS Level II code M1253 denotes a patient-reported disavowal on the patient experience HU survey, indicating the patient states they did not receive care from the listed ambulatory palliative care provider in the previous 60 days. The code is used to document patient-reported encounter status and to reconcile records in ambulatory palliative care programs. Nationally, accurate documentation of patient-reported receipt or non-receipt of services supports quality measurement, provider attribution, and administrative reconciliation.

Key payers covered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an explanation of the code's clinical and administrative purpose, guidance on typical use in ambulatory palliative care settings, and a summary of the types of analyses and benchmarks this code informs. The publication highlights where this code fits within patient experience workflows, common operational considerations, and the implications for reporting and record accuracy.

This summary is written for a national audience and focuses on the code's role in documenting patient-reported encounter status, how it interacts with quality measurement and administrative reconciliation, and what professionals should know about its application in ambulatory palliative care environments.

Billing Code Overview

HCPCS Level II code M1253 describes a patient-reported disavowal on the patient experience HU survey indicating that the patient did not receive care from the listed ambulatory palliative care provider in the prior 60 days. This code captures the patient's statement of non-receipt of ambulatory palliative care services, recorded as part of patient experience or encounter verification processes.

Service type: Patient-reported encounter status / survey disavowal
Typical site of service: Ambulatory palliative care settings (outpatient clinics, ambulatory care centers)

Data not available in the input.

Clinical Context

A typical patient scenario involves a patient who receives a routine patient experience survey (Patient Health United survey) after contact with an ambulatory palliative care program. The patient indicates they did not receive care from the listed ambulatory palliative care provider within the prior 60 days (a disavowal). Clinical workflow: staff reconcile the survey response against visit records, document the disavowal in the electronic health record, flag the patient record for quality reporting reconciliation, and, if required by payer or program rules, submit billing or encounter clarification including the HCPCS Level II code M1253 to denote the patient-reported disavowal. Typical site of service is ambulatory clinic / outpatient palliative care practice where patient experience surveys are administered and quality reporting is managed.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	When work required is substantially greater than typically required for the service being reported in associated encounter documentation
`23`	Unusual anesthesia

Taxonomy Code	Specialty	Notes
`A-MED`	Palliative Medicine	Outpatient palliative care clinicians who manage symptom control and advance care planning
`A-GEN`	Family Medicine / General Practice	Primary care clinicians engaged in ambulatory palliative support and survey follow-up
`A-INT`	Internal Medicine	Internal medicine physicians participating in ambulatory palliative services
`A-NUR`	Nurse Practitioner	Advanced practice providers who often coordinate patient experience follow-up
`A-SWN`	Social Worker	Behavioral health and care coordination staff involved in survey reconciliation

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z68.1`	Body mass index (BMI) 19.9 or less, adult	Example of comorbidity commonly managed in palliative populations where outpatient surveys may be used
`Z51.5`	Encounter for palliative care	Directly relevant diagnosis category indicating the patient is under palliative care and subject to patient experience measurement
`R45.82`	Altered mood, unspecified	Symptom commonly addressed in ambulatory palliative care that may be documented during survey reconciliation
`Z76.89`	Persons encountering health services in other specified circumstances	Administrative code applicable when documenting non-treatment encounters such as survey-only contacts
`Z02.89`	Encounter for administrative examinations, other specified	Used for administrative encounters including survey verification and record reconciliation

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99401`	Preventive medicine counseling, individual; typically 15 minutes	May be performed during ambulatory visits where patient experience is collected and documented prior to or after disavowal reconciliation
`99406`	Smoking and tobacco cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Example of brief counseling services documented in outpatient palliative encounters near survey administration
`99497`	Advance care planning including explanation and discussion of advance directives, first 30 minutes	Commonly performed by palliative clinicians in ambulatory settings where patient identity of provider and services are confirmed
`99080`	Special reports and forms; additional documentation or special reports to third parties	Used when submitting supplemental documentation to payers or quality reporting entities about survey disavowal and reconciliation
`G0438`	Annual wellness visit, first visit	Related preventive or care coordination visits in outpatient settings where patient surveys may be distributed and reconciled

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Summary & Overview

HCPCS M1253: Ambulatory Palliative Care Patient Disavowal