M1346 HCPCS Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1346: No Net PAM Score Increase (4–12 Months)

HCPCS Level II code M1346 identifies patients who did not achieve a meaningful improvement in Patient Activation Measure (PAM) — defined as a net increase of at least 6 points — during a 4 to 12 month follow-up. The code captures outcome-based assessment rather than a discrete procedure, signaling payers’ and providers’ interest in measuring longitudinal patient engagement and self-management progress. Nationally, such measures matter for value-based care programs, quality reporting, and care management performance monitoring.

Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on the clinical purpose of the code, typical service settings (outpatient and ambulatory care, care management programs), and the role of PAM as an outcome metric. The publication outlines benchmarks and reporting implications where available, summarizes policy and payment considerations tied to outcome tracking, and explains how M1346 fits into quality measurement workflows.

Data not available in the input for payer-specific rates, taxonomies, ICD-10 linkage, common claim modifiers, and related codes.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1346HCPCS Level IIPatient Activation Measureoutcome assessmentambulatory carecare managementquality measurementvalue-based carefollow-up assessment

Billing Code Overview

HCPCS Level II code M1346 describes patients who did not have a net increase in PAM score of at least 6 points within a 4 to 12 month period. The service implied is a standardized outcome assessment tied to patient activation measure (PAM) scoring over a multi-month follow-up window. Typical site of service is outpatient or ambulatory care settings where longitudinal patient engagement and outcome measurement occur, such as primary care clinics, specialty ambulatory programs, or care management services.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult enrolled in a chronic disease self-management program who completed baseline Patient Activation Measure (PAM) assessment and subsequent reassessment at 4–12 months. The patient has not achieved a net increase of at least 6 points on the PAM score despite participation in education, coaching, or behavioral interventions. Clinic workflow: initial intake with PAM baseline, delivery of structured interventions (self-management education, motivational interviewing, care coordination) over months, documentation of services and interventions in the medical record, repeat PAM administration at 4–12 months, comparison of scores, and generation of the outcome status used for quality reporting and billing. Typical site of service is outpatient primary care clinic, behavioral health clinic, chronic care management program, or community-based disease management setting. Typical patient scenario: a 58-year-old with type 2 diabetes and hypertension enrolled in a 6‑month self-management program who attends monthly coaching visits, receives educational materials, and participates in medication reconciliation and goal setting, but whose repeat PAM score at 6 months is unchanged or improved by fewer than 6 points from baseline, triggering application of M1346 for reporting of non-improvement within the 4–12 month interval.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services

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

HCPCS-M1331-RE-EVALUATION-WITHIN-8-WEEKS

HCPCS M1331: Re-evaluation Within Eight Weeks

HCPCS-M1290-PATIENT-EXCLUDED-ACTIVE-HYPERTENSION

HCPCS M1290: Patient Excluded for Active Hypertension

HCPCS-M1179-PNEUMOCOCCAL-VACCINE-NOT-RECEIVED-ADULT

HCPCS M1179: Adult Pneumococcal Vaccine Not Received

HCPCS-M1184-DOCUMENTATION-MEDICAL-REASON-NO-CORTICOSTEROID-OR-IMMUNOSUPPRESSANT

HCPCS M1184: Documentation of Medical Reason for Not Prescribing Corticosteroid/Immunosuppressant

HCPCS-M1336-SHORT-INTERVAL-REEVALUATION-IN-OUTPATIENT-SETTING

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

HCPCS-M1467-LYNCH-SYNDROME-GENETIC-COUNSELING-MANAGEMENT

HCPCS Level II M1467: Care for Patients with Lynch Syndrome

HCPCS-M1476-COGNITIVE-IMPAIRMENT-ALZHEIMERS-CARE

HCPCS M1476: Cognitive Impairment and Alzheimer's Disease Services

HCPCS-LEVEL-II-M1326-HYPOTONY-EVALUATION-MANAGEMENT

HCPCS Level II M1326: Patients with Diagnosis of Hypotony

HCPCS-M1203-ACE-ARB-THERAPY-NOT-PRESCRIBED-REASON-NOT-GIVEN

HCPCS M1203: ACE inhibitor or ARB therapy not prescribed, reason not given

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who manage chronic disease and coordinate self-management programs.
`208D00000X`	General Practice	Clinicians providing longitudinal outpatient care and program enrollment.
`2084P0800X`	Behavioral Health & Wellness	Clinicians delivering behavioral interventions, coaching, and motivational interviewing.
`370200000X`	Diabetes Educator	Certified diabetes educators who administer PAM and provide structured self-management education.
`363L00000X`	Clinical Social Worker	Providers delivering counseling, care coordination, and community resource linkage.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E11.9`	Type 2 diabetes mellitus without complications	Common chronic disease target for self-management programs where PAM is used to measure activation and behavior change.
`I10`	Essential (primary) hypertension	Frequently comorbid condition managed within chronic care programs assessed by PAM.
`E78.5`	Hyperlipidemia, unspecified	Common cardiovascular risk factor addressed through lifestyle and medication adherence counseling measured by PAM.
`F41.9`	Anxiety disorder, unspecified	Behavioral health conditions that affect self-management capacity and PAM scores.
`F32.9`	Major depressive disorder, single episode, unspecified	Depression negatively impacts patient activation and is commonly screened in programs using PAM.
`M54.5`	Low back pain	Common chronic pain condition where self-management and activation influence functional outcomes and PAM tracking.
`Z71.89`	Other specified counseling	Encounter-level code for counseling services provided as part of a self-management program tied to PAM measurement.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common visit code used for follow-up coaching, counseling, and documentation of PAM reassessment and interpretation.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Example of a behavioral counseling CPT often provided in the same chronic disease management visit where PAM is reassessed.
`99490`	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month	Programmatic care management code used in longitudinal programs that include PAM monitoring; documents non-face-to-face care coordination supporting the intervention.
`G0511`	Rural health clinic or federally qualified health center visit for chronic care management	Facility-specific visit code that may be used when PAM-based program is administered in these settings.
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory) per standardized instrument, 1 scoring and documentation	Analogous short instrument code used when clinics bill for standardized brief assessments alongside PAM administration.

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