Summary & Overview
HCPCS M1365: Hospice and Palliative Care Patient Encounter
HCPCS Level II code M1365 denotes a patient encounter during the performance period associated with hospice and palliative care specialty code 17. The code is used to document and report clinical encounters for patients receiving hospice or palliative services, and it supports quality measurement and administrative tracking across care settings. Nationally, accurate use of M1365 informs hospice program reporting, payment validations, and continuity-of-care records for seriously ill patients.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code's clinical intent, typical sites of service (hospice inpatient units, home hospice, and palliative care clinics), and the contexts in which the code is applied. The publication provides benchmarks and policy context where available, clarifies common billing modifiers and service-line relationships, and links M1365 to broader hospice and palliative care reporting initiatives.
This summary is written for a national audience and focuses on the code's purpose, payer coverage relevance, and what professionals need to know when encountering M1365 in claims or quality reporting workflows. Data not available in the input will be noted where applicable.
Billing Code Overview
HCPCS Level II code M1365 describes a patient encounter during the performance period with hospice and palliative care specialty code 17. This code represents a documented encounter between a patient and hospice or palliative care clinicians during an established performance period for quality measurement or reporting tied to specialty code 17.
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Service type: Hospice and palliative care encounter
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Typical site of service: Hospice settings or palliative care venues, including inpatient hospice units, home hospice, and palliative care clinics
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Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves an adult with a life-limiting illness enrolled in hospice or receiving palliative care who has an encounter with a hospice/palliative care specialist (specialty code 17) during the performance reporting period. The patient is often homebound or in a nursing facility and may have progressive cancers, advanced heart failure, end-stage lung disease, or neurodegenerative conditions. The encounter documents goals-of-care discussions, symptom management (pain, dyspnea, nausea, delirium), medication reconciliation, psychosocial support, and coordination with the interdisciplinary hospice team.
A common clinical workflow begins with a nurse or social worker identifying a change in symptoms or goals and notifying the hospice/palliative physician or advanced practice clinician. The clinician performs a focused history and symptom assessment, adjusts medications or orders palliative interventions, documents advance care planning and decision-making capacity, and communicates the plan to family and the hospice team. The encounter is coded to reflect the hospice and palliative care specialty (M1365) for performance reporting and quality measurement during the specified performance period.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when the encounter required substantially greater work than typical (e.g., extensive complex goals-of-care discussion documented). |