M1318 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1318: No Contact with Community Support Provider After Positive HRSN Screening

HCPCS Level II code M1318 indicates that a patient who screened positive for one or more high-risk social needs (hrsn) did not have documented contact with a community support provider (csp) within 60 days after screening, or that documentation explicitly records no contact with a csp. Nationally, this code matters for tracking follow-up on social-determinants-of-health screenings, care coordination gaps, and program compliance related to addressing patients' social needs. It can inform quality measurement, care-management workflows, and population health initiatives focused on social risk mitigation.

Key payers included in the scope of discussion are Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Readers will find benchmarks and contextual interpretation of M1318 use across payer policies, implications for clinical documentation and care coordination workflows, and how the code aligns with broader initiatives to address social determinants of health. The publication provides a policy-focused overview, practical coding context, and notes on typical service settings where M1318 would be applied.

Data not available in the input for associated taxonomies, specific ICD-10 pairings, or related codes; those elements are not included here.

AetnaBlue Cross Blue ShieldCignaUnitedHealthcareMedicareM1318HCPCS Level IIsocial determinants of healthcare coordinationfollow-up documentationcommunity support providerpopulation healthquality measurement

Billing Code Overview

HCPCS Level II code M1318 documents instances where patients did not have documented contact with a community support provider (csp) for at least one of their screened positive high-risk social needs (hrsn) within 60 days after screening, or where there is documentation that no contact with a csp occurred. The code captures follow-up or lack thereof related to positive social-needs screening results.

Service type: Follow-up/monitoring of social-needs screening results; documentation of absence of contact with a community support provider
Typical site of service: Outpatient clinical settings where social-needs screening and care coordination occur (for example, primary care clinics, behavioral health clinics, community health centers, or care coordination services).

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A primary care clinic performs routine health-related social needs (HRSN) screening during adult annual visits. A 48-year-old patient screens positive for housing instability and transportation barriers. The clinic documents the screening in the electronic health record (EHR) and attempts referral to a community service provider (CSP) for care coordination. Over the next 60 days there is no documented contact between the patient and the assigned CSP, nor is there documentation that contact did not occur. The clinic must record this outcome for quality tracking and billing under code M1318. Typical workflow: initial HRSN screening during the office visit; referral placed to CSP with contact information and consent; outreach attempts by clinic care coordinator are logged; EHR is reviewed at or after 60 days to determine whether documented CSP contact occurred; if no CSP contact is documented (or documentation states no contact), M1318 is reported to indicate lack of documented CSP contact for at least one screened positive HRSN within 60 days after screening. Typical site of service is outpatient primary care clinic, patient-centered medical home, or community health center where HRSN screening and referral processes are performed.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services

HCPCS Level II M1305: Adult Pneumococcal Vaccination

HCPCS-M1240-PATIENT-NO-RESPONSE-PROVIDER-BEST-INTERESTS-QUESTION

HCPCS M1240: Patient Nonresponse to Provider Best-Interests Question

HCPCS-M1425-SURGICAL-CARE-MIPS-VALUE-PATHWAY

HCPCS M1425: Surgical Care MIPS Value Pathway

HCPCS-M1328-ACUTE-VITREOUS-HEMORRHAGE-EVALUATION

HCPCS Level II M1328: Acute Vitreous Hemorrhage Evaluation

HCPCS-M1263-HOSPICE-DIALYSIS-INITIATION-EVALUATION

HCPCS M1263: Hospice Patient Evaluation at Dialysis Initiation

HCPCS-M1478-PSYCHOACTIVE-SUBSTANCE-ABUSE-TREATMENT

HCPCS Level II M1478: Psychoactive Substance Abuse Services

HCPCS-M1183-IMMUNE-CHECKPOINT-INHIBITOR-HELD-STEROIDS-PRESCRIBED

HCPCS M1183: Immune Checkpoint Inhibitor Held, Steroids/Immunosuppressants Prescribed

HCPCS-M1245-PATIENT-REPORTED-PROVIDER-SAW-ME-AS-A-PERSON

HCPCS Level II M1245: Patient-Reported Provider Saw Me as a Person

HCPCS-M1166-PATHOLOGY-REPORT-WIDE-LOCAL-EXCISION-REEXCISION

HCPCS M1166: Pathology Report for Wide Local Excision/Re-excision

HCPCS-M1479-ASSESSMENT-IMPACT-FUNCTIONAL-CAPACITY-MOTIVATION

HCPCS M1479: Assessment Impacted by Functional Capacity or Motivation

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who perform HRSN screening and initial referrals.
`208000000X`	Internal Medicine	Adult primary care providers managing HRSN screening and care coordination.
`362QA0000X`	Social Worker	Licensed clinical social workers involved in screening, referral, and community resource linkage.
`363L00000X`	Care Coordinator / Community Health Worker	Staff who manage outreach and documentation of CSP contact attempts.
`363A00000X`	Nurse Practitioner	Advanced practice providers performing screening, referral, and follow-up documentation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z59.0`	Homelessness	Directly related to housing instability identified on HRSN screening; may prompt CSP referral and tracking of contact.
`Z59.4`	Lack of adequate food and safe drinking water	Relevant when food insecurity is a screened positive HRSN requiring CSP linkage and documentation of contact.
`Z59.6`	Low income	Social determinant that commonly co-occurs with other HRSNs and justifies referral to community resources.
`Z60.2`	Problems related to living alone	May be relevant when social isolation or lack of support resources are identified on screening.
`Z59.8`	Other problems related to housing and economic circumstances	Captures housing- or economic-related HRSNs that require CSP referral and follow-up.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	May be performed during the same primary care visit when HRSN screening occurs; often billed alongside screening-related counseling.
`99407`	Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes	Same-visit behavioral intervention that can accompany HRSN screening and referral activities.
`99401`	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (approximately 15 minutes)	Preventive counseling commonly delivered during visits that include HRSN screening and referral.
`99490`	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	Used when ongoing care coordination, including HRSN outreach and community service linkage, is billed as chronic care management.
`99487`	Complex chronic care management services, with at least 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	Applies when extensive care coordination and documentation for social needs and CSP linkage are required as part of complex chronic care management.

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