HCPCS M1354: Suicide Safety Plan Not Initiated or Reviewed - OpenPayer

Summary & Overview

HCPCS M1354: Suicide Safety Plan Not Initiated or Reviewed

HCPCS Level II code M1354 denotes the absence of initiation, review, or collaborative updating of a suicide safety plan within specified timeframes surrounding a clinical encounter. The code addresses documentation gaps in suicide risk management and care continuity, an area of national focus given rising attention to behavioral health outcomes and patient safety. This code matters nationally because timely suicide safety planning is a recognized element of quality behavioral health care and care transitions.

Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical intent, typical settings and service type (behavioral health follow-up and coordination), and implications for documentation and quality measurement. The publication summarizes benchmarks and reporting considerations where available, outlines common payer coverage patterns, and reviews related policy and clinical context relevant to suicide prevention workflows.

The content offers practical clarity on how HCPCS Level II code M1354 is used to identify missed opportunities for suicide safety planning, informs coding and quality measurement discussions, and situates the code within national behavioral health quality priorities. Data not available in the input are noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1354HCPCS Level IIsuicide safety planbehavioral healthcare coordinationquality measurementdocumentationmental healthfollow-up

Billing Code Overview

HCPCS Level II code M1354 indicates that a patient did not have a suicide safety plan initiated, reviewed, or updated, or reviewed and updated in collaboration with the patient and their clinician either concurrently or within 24 hours of a clinical encounter and within 120 days after initiation. This measure captures the absence of documentation that a suicide safety plan was started or subsequently reviewed and updated in the specified timeframes.

Service type: Behavioral health follow-up and care coordination related to suicide prevention
Typical site of service: Mental health clinics, outpatient behavioral health settings, emergency departments, primary care settings where behavioral health follow-up is provided

Clinical & Coding Specifications

Clinical Context

A typical patient is a 28-year-old adult presenting to an outpatient behavioral health clinic after a recent episode of suicidal ideation reported during a telehealth psychiatric follow-up. The clinician documents that a suicide safety plan was not initiated, reviewed, or updated within 24 hours of the clinical encounter and that no review or update occurred within 120 days after plan initiation. The clinical workflow begins with triage by a licensed clinical social worker or nurse who documents the current risk level and history. The treating psychiatrist or licensed therapist conducts a focused risk assessment and documents decision-making but does not complete a formal safety plan in collaboration with the patient. The encounter note includes reason for omission (e.g., patient declined, emergent transfer, or clinical instability) and any interim risk mitigation steps (e.g., emergent referral to emergency services, caregiver notification). Billing staff assign M1354 for cases meeting the code description and append appropriate modifiers corresponding to payer requirements and encounter circumstances. Typical sites of service include outpatient mental health clinics, community behavioral health centers, and telehealth settings. Common patient scenarios involve follow-up for major depressive disorder with suicidal ideation, partial hospitalization patients transitioning to outpatient care, or patients seen urgently after self-harm assessment who require escalation of care before a collaborative safety plan can be completed.

Coding Specifications

Modifier	Description	When to Use

HCPCS M1403: PROMIS Baseline and Follow-Up Survey Documentation

HCPCS-M1410-NO-BRCA-GERMLINE-TESTING-OR-GENETIC-COUNSELING-6-MONTHS

HCPCS M1410: No BRCA1/BRCA2 Germline Testing or Genetic Counseling

HCPCS-M1376-RA-ADDITIONAL-ENCOUNTER-90-DAY-RULE

HCPCS Level II M1376: Additional RA Encounter, ≥90 Days

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

HCPCS M1425: Surgical Care MIPS Value Pathway

HCPCS-M1373-GLYCEMIC-STATUS-HBA1C-8-TO-9-PERCENT

HCPCS Level II M1373: Glycemic Status Assessment, HbA1c/GMI 8.0–9.0%

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

HCPCS M1383: Acute Peripheral Vascular Disease Assessment

HCPCS-M1273-SNF-ADMISSION-WITHIN-ONE-YEAR-OF-DIALYSIS-INITIATION

HCPCS Level II M1273: SNF Admission Within One Year of Dialysis Initiation

HCPCS-M1344-MISSING-BASELINE-OR-FOLLOWUP-PAM-SCORE

HCPCS M1344: Missing Baseline or Follow-up Patient Activation Measure

HCPCS-M1211-MOST-RECENT-HBA1C-GMI-OVER-9-0

HCPCS Level II M1211: Most Recent Glycemic Status Assessment >9.0%

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

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

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Taxonomy Code	Specialty	Notes
`103K00000X`	Clinical Social Worker	Frequently performs risk assessments and documents safety planning conversations.
`2084P0800X`	Psychiatrist	Provides diagnostic evaluation, high-risk management, and oversight of safety planning.
`101Y00000X`	Nurse Practitioner	Performs assessments and may initiate or update safety plans in collaboration with supervising physicians.
`106H00000X`	Psychologist	Conducts psychotherapy and risk assessment; documents safety planning discussions.
`363L00000X`	Licensed Professional Counselor	Provides outpatient counseling and may collaborate on safety plans with the patient.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F32.1`	Major depressive disorder, single episode, moderate	Common diagnosis linked to suicidal ideation where safety planning is standard but may be omitted in some encounters.
`F32.9`	Major depressive disorder, single episode, unspecified	Frequently encountered in outpatient follow-up visits where a safety plan should be reviewed or updated.
`F33.1`	Major depressive disorder, recurrent, moderate	Recurrent depression increases suicide risk and typically prompts safety planning.
`F41.1`	Generalized anxiety disorder	Anxiety disorders can co-occur with suicidal ideation; safety planning may be part of management.
`F43.23`	Adjustment disorder with mixed anxiety and depressed mood	Acute stressors can precipitate suicidal thoughts and the need for a safety plan.
`R45.851`	Suicidal ideation	Directly indicates the clinical need for initiation, review, or update of a suicide safety plan.
`T14.91`	Suicide attempt, initial encounter	Represents encounters following self-harm where safety planning is a critical element of follow-up care.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`90832`	Psychotherapy, 30 minutes with patient	May be performed during the same visit when a focused therapy session occurs but a formal safety plan was not completed.
`90834`	Psychotherapy, 45 minutes with patient	Commonly billed for standard individual therapy visits where safety planning is typically part of the session.
`90837`	Psychotherapy, 60 minutes with patient	Used for extended psychotherapy visits that often include comprehensive risk assessment and safety planning when completed.
`90791`	Psychiatric diagnostic evaluation (no medical services)	Often performed at initial evaluation visits where a suicide safety plan would be initiated; if absent, `M1354` may apply.
`90792`	Psychiatric diagnostic evaluation with medical services	Used when an evaluation includes medical management; relates to safety planning workflow when such a plan is not documented.
`H2011`	Crisis intervention service, per 15 minutes (HCPCS Level II-like but used in some panels)	Performed during acute crisis encounters; crisis intervention may occur without a completed safety plan, making `M1354` relevant.

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