M1336 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1336: Re-evaluation within 2 Weeks of Initial Exam

HCPCS Level II code M1336 documents a clinical scenario in which a patient who received an appropriate initial evaluation is re-evaluated within two weeks. Nationally, short-interval re-evaluations support continuity of care, rapid response to changing clinical status, and appropriate adjustment of treatment plans. Payers and providers use this code to capture services tied to follow-up clinical assessment shortly after an initial visit.

This publication covers major payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of how M1336 is defined, typical clinical contexts and sites of service, and the payer mix included in the analysis. The report summarizes benchmark usage patterns, relevant billing considerations, and any recent policy clarifications that affect national reimbursement and documentation expectations. The goal is to provide clinicians, coders, and policy analysts with clear context on when M1336 applies and what elements are commonly reviewed when billing for a short-interval re-evaluation within two weeks of an initial exam.

Data not available in the input for associated taxonomies, ICD-10 diagnoses, and related codes.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1336HCPCS Level IIreevaluationfollow-up visitoutpatient careshort-interval follow-upclinical documentation

Billing Code Overview

HCPCS Level II code M1336 describes patients who were appropriately evaluated during the initial exam and were re-evaluated no later than 2 weeks. This code represents a short-interval re-evaluation service following an initial assessment.

Service type: Short-interval clinical re-evaluation following an initial exam
Typical site of service: Ambulatory clinic or outpatient setting where initial evaluation and follow-up re-evaluation occur

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult who presented for an initial evaluation of a musculoskeletal or functional complaint (for example, acute low back pain or a post-operative wound check). The clinician performed a comprehensive initial exam documenting history, systems review, and objective assessment, established a treatment plan, and scheduled a re-evaluation within two weeks. At the re-evaluation visit the provider documents interval history, response to treatment, objective findings, and any modification to the plan of care. Typical workflow: initial visit with baseline measures (pain score, range of motion, functional status), initiation of conservative treatments or ordered interventions, scheduled short-interval follow-up within 14 days, focused re-evaluation to assess progress and determine next steps. Typical site of service is an outpatient clinic or ambulatory surgical center. The scenario commonly applies to patients receiving therapy or post-procedure follow-up where early reassessment is clinically indicated to verify appropriate response to treatment and to adjust care promptly. Example modifiers that may be appended to claims include 22 for increased procedural services or 52 for reduced services when applicable.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services

HCPCS Level II M1321: Post-Injection Ophthalmic Follow-Up Documentation

HCPCS-M1317-COUNSELING-CSP-CONNECTION-OPT-OUT

HCPCS M1317: Counseling on Community Service Provider Connection, Patient Opt-Out

HCPCS-M1349-PATIENT-ACTIVATION-NO-NET-PAM-IMPROVEMENT-4-12-MONTHS

HCPCS M1349: No Net PAM Score Improvement (4–12 Month Follow-Up)

HCPCS-M1191-HOSPICE-SERVICES-ANY-TIME-DURING-MEASUREMENT-PERIOD

HCPCS M1191: Hospice Services During Measurement Period

HCPCS-M1197-ITCH-SEVERITY-ASSESSMENT-SCORE-IMPROVEMENT

HCPCS M1197: Itch Severity Assessment, 3+ Point Improvement

HCPCS-M1332-INADEQUATE-INITIAL-EVALUATION-FOLLOW-UP

HCPCS M1332: Inadequate Initial Evaluation or Missed 2-Week Re-evaluation

HCPCS-M1374-RA-ADDITIONAL-ENCOUNTER-90-DAYS

HCPCS M1374: Additional Rheumatoid Arthritis Encounter, 90+ Days

HCPCS-M1267-KIDNEY-TRANSPLANT-WAITLIST-INACTIVE-STATUS

HCPCS Level II M1267: Kidney/Kidney-Pancreas Transplant Waitlist Inactive Status

HCPCS-M1369-QUALITY-CARE-MENTAL-HEALTH-SUBSTANCE-USE-MIPS-VALUE-PATHWAY

HCPCS M1369: Quality Care for Mental Health and Substance Use Disorders

HCPCS-M1350-SUICIDE-SAFETY-PLAN-INITIATED-REVIEWED-UPDATED

HCPCS M1350: Suicide Safety Plan Initiation, Review, or Update

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Taxonomy Code	Specialty	Notes
207L00000X	Physical Medicine & Rehabilitation	Commonly performs initial evaluation and short-interval re-evaluation for functional recovery and therapy planning.
225100000X	Orthopedic Surgery	Frequently manages post-operative re-evaluation and early follow-up for musculoskeletal procedures.
207RH0000X	Rehabilitation Medicine (Physical Therapist)	Provides focused re-evaluations in outpatient therapy when appropriate and billable under specific payor rules.
207P00000X	Physical Therapy	Performs re-evaluations to document progress and adjust therapeutic interventions in outpatient settings.
363A00000X	Anesthesiology (when anesthesia-related modifier `23` applies)	Involved when unusual anesthesia events occur during procedures associated with the re-evaluation.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M54.5`	Low back pain	Frequently prompts initial evaluation and short-interval re-evaluation to assess response to conservative care.
`M25.50`	Pain in unspecified joint	Common presenting complaint where an early re-evaluation documents treatment effect and functional change.
`S72.001A`	Fracture of unspecified part of neck of right femur, initial encounter for closed fracture	Example post-procedural scenario where early re-evaluation within two weeks assesses healing and complications.
`Z47.89`	Other orthopaedic aftercare	Used for post-operative or device-related follow-up visits requiring early reassessment.
`M54.2`	Cervicalgia	Cervical pain evaluations often include short-interval rechecks to guide therapy or interventional planning.
`M96.1`	Postlaminectomy syndrome, not elsewhere classified	Post-surgical patients may require close early re-evaluation to address pain control and wound issues.
`Z09`	Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm	Applicable when the re-evaluation documents treatment response following an initial therapeutic episode.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99202`	Office or other outpatient visit for the evaluation and management of a new patient, typically 15–29 minutes	May be used for the initial evaluation visit preceding a two-week re-evaluation when a new outpatient E/M was performed.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Commonly used for focused interim follow-up or re-evaluation visits in an outpatient clinic.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used when the two-week re-evaluation involves moderate complexity medical decision making and expanded documentation.
`97161`	Physical therapy evaluation, low complexity	May be used for the initial therapy evaluation when subsequent re-evaluation within two weeks is performed to assess response.
`97164`	Re-evaluation of physical therapy established plan of care	Directly aligns with a focused re-evaluation performed within the short interval to document progress and modify the plan.
`99024`	Postoperative follow-up visit, normally included in the surgical package, unless reported separately for global period exceptions	Relevant when the re-evaluation occurs in the post-operative period and payer rules permit separate billing.

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