M1275 Hospice Exclusion (HCPCS) Reimbursement | OpenPayer

Summary & Overview

HCPCS M1275: Hospice Exclusion From Evaluation and Reporting

HCPCS Level II code M1275 denotes that a patient was identified as being in hospice and therefore excluded from the month of evaluation and the remainder of the reporting period. This code is used in administrative and quality-reporting contexts to mark patients whose hospice enrollment alters eligibility for certain measures or program counts. Nationally, accurate use of exclusion codes like M1275 affects performance measurement, provider reporting integrity, and downstream payment reconciliation.

Key payers covered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will learn how M1275 is applied in reporting workflows, the clinical context in which hospice exclusion is documented, and the implications for quality measurement and administrative records. The publication outlines typical scenarios for assigning the code and discusses where this designation is most commonly recorded (hospice programs, home hospice, and hospital discharge processes).

The content provides practical benchmarks and policy context where available and flags areas where input data was not provided. It is written for a national audience of billing managers, compliance officers, and health policy analysts seeking a concise reference on hospice exclusion reporting and its administrative impact.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1275HCPCS Level IIhospicequality reportingeligibility exclusionadministrative codereporting periodhospice enrollment

Billing Code Overview

HCPCS Level II code M1275 indicates that a patient was determined to be in hospice and therefore was excluded from the month of evaluation and the remainder of the reporting period. This designation is used when hospice status affects eligibility for reporting or program measurement during a defined reporting window.

Service type: Eligibility/Reporting exclusion related to hospice status

Typical site of service: Hospice setting or any site where hospice status is determined and reported, including inpatient hospice units, home hospice, and hospital discharge settings where hospice enrollment is documented.

Clinical & Coding Specifications

Clinical Context

Patients determined to be in hospice were excluded from month of evaluation and the remainder of reporting period. A typical scenario involves a primary care physician or palliative care team documenting that a patient with advanced, progressive illness elected or was placed on hospice care beginning mid-reporting period. The clinical workflow begins with the hospice eligibility determination (physician certification that life expectancy is six months or less if the disease runs its normal course), documentation of the hospice election date in the medical record, and notification of billing and quality teams. For quality reporting and claims adjudication, the patient is excluded from measure denominators for the month of evaluation and for all subsequent months in the reporting period after the hospice start date. Usual sites of service include inpatient hospice units, home hospice visits, long-term care facilities, and outpatient palliative care clinics. Key stakeholders in the workflow are the attending physician or hospice medical director, hospice nurse, case manager, medical records coder, and billing specialist who applies exclusion coding or modifiers as appropriate for reporting and claims reconciliation.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when substantially greater work than usual is documented for associated services before hospice exclusion is applied.

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HCPCS-M1232-HCV-ANTIBODY-TEST-REACTIVE-RESULT

HCPCS M1232: HCV Antibody Test, Reactive Result

HCPCS-M1219-ANAPHYLAXIS-VACCINE-REACTION-ENCOUNTER

HCPCS Level II M1219: Anaphylaxis Due to Vaccine on or Before Encounter Date

HCPCS-M1499-INTERVENTIONAL-RADIOLOGY-MIPS-VALUE-PATHWAY

HCPCS Level II M1499: Interventional Radiology MIPS Value Pathway

HCPCS-M1151-HEART-TRANSPLANT-LVAD-STATUS

HCPCS M1151: Heart Transplant Status or LVAD Support

HCPCS-M1442-TELEHEALTH-ENCOUNTER-VISIT-VIRTUAL-CARE

HCPCS Level II M1442: Telehealth Encounter / Virtual Visit

HCPCS-M1290-PATIENT-EXCLUDED-ACTIVE-HYPERTENSION

HCPCS M1290: Patient Excluded for Active Hypertension

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

HCPCS Level II M1310: Tobacco Use Screening and Cessation Intervention

HCPCS-M1187-END-STAGE-RENAL-DISEASE-ESRD-CARE

HCPCS M1187: End Stage Renal Disease (ESRD) Care

HCPCS-M1421-DERMATOLOGY-MIPS-VALUE-PATHWAY

HCPCS Level II M1421: Dermatology MIPS Value Pathway

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Taxonomy Code	Specialty	Notes
207Q00000X	Family Medicine	Primary physicians who document hospice eligibility and coordinate care.
208000000X	Internal Medicine	Hospitalists and primary internists involved in hospice decision-making.
185H00000X	Hospice and Palliative Medicine	Specialists who certify hospice eligibility and manage end-of-life care.
163W00000X	Nurse Practitioner	NPs who provide hospice care, documentation, and follow-up.
282N00000X	Registered Nurse	Hospice nurses who document admission date and clinical status.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C80.1`	Malignant (primary) neoplasm, unspecified	Advanced cancer is a common hospice diagnosis leading to hospice election and exclusion from measure reporting.
`I50.9`	Heart failure, unspecified	End-stage heart failure frequently results in hospice enrollment and reporting exclusions.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	Severe COPD with progressive decline may prompt hospice care and exclusion.
`G30.9`	Alzheimer's disease, unspecified	Advanced dementia is a frequent hospice primary diagnosis affecting reporting status.
`N18.6`	End stage renal disease	Patients with ESRD who elect comfort-focused care are commonly placed on hospice and excluded from measures.
`R99`	Ill-defined and unknown cause of mortality	Used in some terminal, non-specific decline situations documented at end of life.

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, typically 30 minutes	May be performed prior to hospice election when assessing needs and documenting plan of care.
`99306`	Initial nursing facility care, per day, for the evaluation and management of a patient, typically 45 minutes	Used for more complex initial assessments before hospice exclusion is applied.
`99324`	Domiciliary or rest home visit for the evaluation and management of a patient	Commonly used for home or residential assessments prior to or at hospice admission.
`99497`	Advance care planning including explanation and discussion of advance directives, first 30 minutes	Often provided during hospice discussions and documented in the record supporting hospice election.
`99498`	Advance care planning, each additional 30 minutes	Used when extended discussions contribute to hospice decision and documentation.

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