M1348 (HCPCS) Reimbursement & Benchmarks | OpenPayer

Summary & Overview

HCPCS M1348: Patient Activation Measure Increase, Excellent

HCPCS Level II code M1348 identifies patients with an excellent response on the Patient Activation Measure (PAM), defined as a net increase of at least 6 points over a 4–12 month interval. As an outcome-based HCPCS code, M1348 signals measurable improvements in patient self-management and engagement, which are increasingly relevant to value-based care models and quality reporting at the national level. Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of what the code represents, the clinical and service settings where PAM assessments are typically delivered, and what inclusion of such an outcome measure implies for billing and performance tracking. The publication also summarizes payer coverage context, common modifiers, and where to look for complementary codes or clinical documentation. Data not provided in the source are noted as unavailable; the focus remains on the clinical meaning, typical service settings, and national relevance of HCPCS Level II code M1348.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1348HCPCS Level IIPatient Activation MeasureOutcome MeasureHome HealthOutpatient CareValue-Based CareQuality Reporting

Billing Code Overview

The HCPCS Level II code M1348 denotes patients who achieved a net increase in Patient Activation Measure (PAM) score of at least 6 points within a 4- to 12-month period, classified as excellent improvement. This code represents an outcome-based performance metric tied to patient activation and self-management capability.

Service Type: Patient activation/outcome measurement

Typical Site of Service: Outpatient clinic, home health, or telehealth settings where PAM assessments are administered and tracked over time

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

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient with type 2 diabetes and obesity enrolls in a structured chronic disease self-management program led by a multidisciplinary team (primary care physician, certified diabetes educator, and behavioral health specialist). Baseline Patient Activation Measure (PAM) is administered at program start. Over a 4–12 month period the patient receives individualized education, telehealth coaching sessions, medication reconciliation visits, and goal-setting encounters. At the 12-month reassessment the patient achieves a net increase in PAM score of at least 6 points, meeting the threshold described by billing code M1348 (excellent). Typical workflow components include documentation of baseline and follow-up PAM scores in the medical record, care plan updates, progress notes showing interventions provided, and a finalized activation score supporting the claim. Typical site of service is outpatient clinic or ambulatory care with possible telehealth follow-up. Common modifiers applied to the claim reflect unusual procedural circumstances, billing jurisdiction, or practitioner employment status.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than usually required (extensive counseling/education beyond typical session).

HCPCS Level II M1239: Patient Did Not Respond to 'Heard and Understood' Question

HCPCS-M1190-KIDNEY-HEALTH-EVALUATION-DOCUMENTATION-MISSING

HCPCS Level II M1190: Documentation Missing for Kidney Health Evaluation

HCPCS-M1259-DIALYSIS-PATIENT-STATUS-FIRST-YEAR

HCPCS M1259: Patient Status Documented Within First Year of Dialysis

HCPCS-M1186-HOSPICE-PALLIATIVE-CARE-ORDER-OR-RECEIVING

HCPCS Level II M1186: Hospice or Palliative Care Order/Receiving

HCPCS-M1383-ACUTE-PERIPHERAL-VASCULAR-DISEASE-ASSESSMENT

HCPCS M1383: Acute Peripheral Vascular Disease Assessment

HCPCS-M1338-FOLLOW-UP-FUNCTIONAL-ASSESSMENT-NO-IMPROVEMENT-30-180-DAYS

HCPCS M1338: Follow-up Functional Assessment, No Improvement (30–180 days)

HCPCS-M1407-PATIENT-DEATH-DURING-FOLLOW-UP

HCPCS Level II M1407: Patients Who Died During Follow-Up

HCPCS-M1209-HIGH-RISK-MEDICATION-DUPLICATE-CLASS-ORDERS-NO-APPROPRIATE-DIAGNOSES

HCPCS M1209: Multiple High-Risk Medication Orders from Same Class

HCPCS-M1268-KIDNEY-KIDNEY-PANCREAS-WAITLIST-ACTIVE-STATUS

HCPCS M1268: Kidney or Kidney–Pancreas Transplant Waitlist Active Status

HCPCS-M1192-ESOPHAGEAL-SQUAMOUS-CELL-CARCINOMA-PATIENT-CLASSIFICATION

HCPCS Level II M1192: Esophageal Squamous Cell Carcinoma, Established Diagnosis

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Taxonomy Code	Specialty	Notes
`208000000X`	Family Medicine	Primary care clinicians who oversee chronic disease self-management and PAM tracking.
`207Q00000X`	Internal Medicine	Internists managing complex chronic conditions and coordination of activation interventions.
`363L00000X`	Nurse Practitioner	Nurse practitioners providing education, coaching, and follow-up visits.
`353L00000X`	Physician Assistant	Physician assistants delivering care management and documentation of PAM results.
`367A00000X`	Health and Wellness Coach	Coaches who deliver behavioral interventions and document PAM improvements.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E11.9`	Type 2 diabetes mellitus without complications	Common chronic condition where patient activation and self-management education yield measurable PAM improvements.
`I10`	Essential (primary) hypertension	Hypertension management often includes education and activation efforts tracked by PAM.
`E78.5`	Hyperlipidemia, unspecified	Lipid management benefits from improved activation and adherence to therapy and lifestyle change.
`F33.1`	Major depressive disorder, recurrent, moderate	Behavioral health conditions affect activation; treatment and coaching can improve PAM scores.
`Z71.89`	Other specified counseling	Counseling services documented in care plans that contribute to PAM increase.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Behavioral counseling commonly performed alongside activation interventions to modify health behaviors.
`99407`	Smoking and tobacco use cessation counseling, intensive, greater than 10 minutes	Longer counseling sessions that may accompany coaching efforts reflected in PAM improvement.
`98960`	Education and training for patient self-management for a single chronic condition, face-to-face; initial 30 minutes	Directly aligns with structured self-management education contributing to PAM increases.
`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	Ongoing care coordination and management services that support interventions measured by PAM.
`99457`	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional, interactive communication	Telehealth/remote monitoring and interactive support used during the 4–12 month period to improve activation.

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