M1274 HCPCS: SNF Exclusion Policy & Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II M1274: SNF Admission Monthly Evaluation Exclusion

HCPCS Level II code M1274 identifies a procedural billing marker used when patients admitted to a skilled nursing facility (SNF) during a given month are excluded from that month’s evaluation period. Nationally, such exclusion codes matter because they affect monthly eligibility counts, quality measurement denominators, and administrative reporting for post-acute and long-term care populations. Key payers in national analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. This publication provides a concise overview of the code’s clinical and administrative meaning, the typical site of service (SNF), and the implications for monthly evaluation workflows. Readers will find: benchmarks and contextual guidance on how exclusion codes intersect with monthly reporting cycles; summaries of payer acceptance practices where available; and the clinical context for when an SNF admission triggers exclusion from an evaluation month. Data not available in the input is noted where applicable. The content is intended for national audiences including billing managers, compliance officers, and policy analysts seeking clarity on how M1274 functions within billing and reporting processes.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1274HCPCS Level IIskilled nursing facilitymonthly evaluationpost-acute carebilling exclusionadministrative codequality measurement

Billing Code Overview

HCPCS Level II code M1274 indicates that patients who were admitted to a skilled nursing facility (SNF) during the month of evaluation were excluded from that month. This code is used to denote exclusion of a monthly evaluation period when a patient’s care included an SNF admission.

Service type: Administrative exclusion related to monthly evaluation period
Typical site of service: Skilled Nursing Facility (SNF) or settings tracking monthly evaluation eligibility

Clinical & Coding Specifications

Clinical Context

A patient enrolled in a managed care plan is under monthly quality measurement review for post-acute care transitions. The patient is a 78-year-old with multiple chronic conditions (for example, congestive heart failure and osteoarthritis) who was receiving home-based primary care but was admitted to a skilled nursing facility (SNF) for a short rehabilitation stay during the month. Per the billing code M1274, any month in which the patient had a SNF admission is excluded from measurement for this specific monthly evaluation. The clinical workflow includes documentation of the SNF admission and discharge dates in the medical record, verification of site-of-service for the month by the coder/quality reviewer, and application of the M1274 exclusion when generating monthly outcome or utilization reports. Typical sites of service affected are Skilled Nursing Facility (SNF) and the patient’s home/community setting. The patient scenario commonly involves care coordination notes, transition-of-care summaries, and claims or encounter data indicating SNF admission that triggers exclusion for that month under the M1274 rule.

Coding Specifications

Modifier	Description

HCPCS M1147: Ongoing Care Discontinued Due to Hospitalization or Surgery

HCPCS-M1494-PATIENT-REPORTED-FALL-SINCE-LAST-VISIT

HCPCS Level II M1494: Patient Reported Fall Since Last Visit

HCPCS-M1310-TOBACCO-CESSATION-SCREENING-AND-INTERVENTION

HCPCS Level II M1310: Tobacco Use Screening and Cessation Intervention

HCPCS-M1226-IOP-NOT-DOCUMENTED-UNKNOWN-REASON

HCPCS M1226: IOP Measurement Not Documented, Reason Unspecified

HCPCS-M1411-FIRST-LINE-IMMUNE-CHECKPOINT-INHIBITOR-NO-CHEMOTHERAPY

HCPCS M1411: First-Line Immune Checkpoint Inhibitor Without Chemotherapy

HCPCS-M1213-SPIROMETRY-NO-CONFIRMED-OBSTRUCTION-CURRENT-NON-OBSTRUCTIVE

HCPCS M1213: Spirometry Assessment, No Prior Confirmed Obstruction

HCPCS-M1280-BILATERAL-MASTECTOMY-HISTORY

HCPCS Level II M1280: Bilateral Mastectomy or History of Bilateral Mastectomy

HCPCS-M1462-HEAD-IMAGING-CLINICAL-INDICATIONS

HCPCS M1462: Head Imaging for Clinical Indications

HCPCS-M1283-TOBACCO-USE-SCREENING-IDENTIFIED-USER

HCPCS M1283: Patient Screened for Tobacco Use, Identified as User

HCPCS-M1434-ORAL-CHEMOTHERAPY-STATUS-POST-ENCOUNTER

HCPCS M1434: Patient on Oral Chemotherapy Near Encounter

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Taxonomy Code	Specialty	Notes
`163W00000X`	Geriatric Medicine	Common specialty managing complex older adults across `SNF` and community settings.
`207Q00000X`	Family Medicine	Provides primary care coordination for patients transitioning to/from `SNF`.
`207R00000X`	Internal Medicine	Manages chronic conditions and coordinates post-acute care where exclusion rules apply.
`363L00000X`	Rehabilitation Medicine	Oversees rehabilitative services commonly delivered in `SNF` stays.
`207P00000X`	Nurse Practitioner	Advanced practice providers who document transition-of-care and site-of-service changes.

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99304`	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires complex or comprehensive assessment	Performed when a patient is newly admitted to a `SNF`; supports documentation of admission dates that trigger `M1274` exclusion.
`99307`	Subsequent nursing facility care, per day, for the evaluation and management of a patient	Used for ongoing `SNF` management during the month; presence of these codes on claims indicates the month should be excluded.
`99315`	Nursing facility discharge day management; 30 minutes or less	Used at `SNF` discharge; documentation supports determining which month(s) are excluded under `M1274`.
`99495`	Transitional care management services with moderate medical decision complexity (face-to-face within 14 days)	Frequently used in transitions from `SNF` to community; timing of this service helps verify the month of `SNF` stay.
`99496`	Transitional care management services with high medical decision complexity (face-to-face within 7 days)	Used for high-complexity transitions and supports claims evidence for applying the `SNF` exclusion.

`22`	Increased procedural services	Use when services are substantially greater than usual; rare for administrative exclusion codes but applicable to associated encounters requiring significantly more work.
`23`	Unusual anesthesia	Use if an unrelated anesthesia service was required for an associated procedure during a month under review.
`52`	Reduced services	Use when a billed service was partially reduced or not completed during the month.
`53`	Discontinued procedure	Use when a planned procedure was started but terminated; may appear on associated claims during a `SNF` stay month.
`54`	Surgical care only	Use when only the surgeon’s portion of care is billed; applicable to related surgical encounters occurring before/after `SNF` admission.
`55`	Postoperative management only	Use when only postoperative care is billed, for care provided after discharge from `SNF`.
`56`	Preoperative management only	Use when only preoperative care was billed prior to `SNF` admission.
`62`	Two surgeons	Use when co-surgeons are required for an associated operative service during the measurement period.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery	Use when an advanced practice clinician bills for assistant surgical services related to a procedure occurring around the `SNF` stay.
`CO`	Workers' Compensation	Use when the claim relates to a workers’ compensation payer for services during or around the `SNF` admission.

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