M1374 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS M1374: Additional Rheumatoid Arthritis Encounter, 90+ Days

HCPCS Level II code M1374 denotes an additional encounter with a rheumatoid arthritis (RA) diagnosis that occurs at least 90 days before or after a qualifying RA encounter within the performance period. This code captures temporally distinct RA visits used in quality measurement and longitudinal tracking of disease management. Nationally, such encounter-level codes matter for quality programs, performance measurement, and documentation of continuity of care for chronic conditions.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find context on the clinical intent of the code, how it is used to mark separate RA encounters over time, and what implications the code has for outpatient or ambulatory care documentation. The publication provides benchmarks and policy-relevant context where available, highlights clinical scenarios in which M1374 is relevant, and notes where input data are not available.

This summary is intended for a national audience of clinicians, coding professionals, and health policy analysts seeking concise guidance on the purpose and application context of HCPCS Level II code M1374 in RA encounter tracking and quality measurement.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1374HCPCS Level IIrheumatoid arthritisoutpatientquality measurementencounter trackingperformance periodambulatory care

Billing Code Overview

HCPCS Level II code M1374 describes an additional encounter with an rheumatoid arthritis (RA) diagnosis during the performance period or a prior performance period that occurs at least 90 days before or after an encounter with an RA diagnosis during the performance period.

Service type: Measurement/encounter tracking for rheumatoid arthritis diagnosis over time, used to document temporally distinct outpatient or ambulatory encounters related to RA.
Typical site of service: Outpatient clinic or ambulatory care settings where RA diagnoses are made and follow-up encounters occur.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient with established rheumatoid arthritis (RA) attends an outpatient rheumatology clinic for routine disease activity assessment and documentation during the performance period. The billing code M1374 is used to report an additional encounter with an RA diagnosis occurring at least 90 days before or after another encounter with an RA diagnosis within the performance period. Typical workflow: patient checks in for evaluation, nurse obtains vitals and patient-reported outcomes (e.g., pain, function), physician or advanced practice provider performs focused joint exam, adjusts medications as needed, documents disease activity (tender/swollen joint counts, CDAI/DAS28 components or RAPID3), and documents the encounter date relative to other RA encounters to satisfy the 90-day timing requirement. Encounters may occur in an outpatient clinic, ambulatory surgery center for infusion visits, or via telehealth depending on payer rules. Common clinical scenarios include medication follow-up after initiating or changing disease-modifying antirheumatic drugs, management of a flare, monitoring response to biologic therapy, or routine chronic disease management when an RA diagnosis is the primary reason for the visit.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when services provided are substantially greater than typical for the encounter and require supporting documentation of additional work.

HCPCS Level II M1366: Women's Health MIPS Value Pathway

HCPCS-M1357-FOLLOW-UP-REDUCTION-IN-SUICIDAL-IDEATION-OR-BEHAVIOR

HCPCS Level II M1357: Reduction in Suicidal Ideation or Behavior

HCPCS-M1262-PRE-DIALYSIS-TRANSPLANT-STATUS

HCPCS Level II M1262: Patients with Transplant Before Dialysis

HCPCS-M1238-RECOMBINANT-ZOSTER-DELAYED-SECOND-DOSE-DOCUMENTATION

HCPCS Level II M1238: Documentation of Delayed Second Recombinant Zoster Dose

HCPCS-M1409-BRCA-GENETIC-TESTING-OR-COUNSELING-WITHIN-6-MONTHS

HCPCS M1409: BRCA1/BRCA2 Germline Testing or Genetic Counseling within 6 Months

HCPCS-M1466-LUMBAR-FUSION-WITH-DISCECTOMY-LAMINECTOMY

HCPCS Level II M1466: Lumbar Fusion with Discectomy/Laminectomy

HCPCS-M1426-TELEHEALTH-ENCOUNTER-VIRTUAL-VISIT

HCPCS M1426: Telehealth Encounter, Virtual Visit

HCPCS-M1325-NOT-SEEN-CLINICIAN-DOCUMENTED-MEDICAL-REASONS

HCPCS Level II M1325: Clinician-Documented Patient Not Seen for Ophthalmic Reasons

HCPCS-M1266-SNF-ADMISSION

HCPCS M1266: Skilled Nursing Facility Admission

HCPCS-M1465-PATIENT-FOLLOW-UP-MORE-THAN-180-DAYS

HCPCS M1465: Patient Follow-Up More Than 180 Days After Treatment

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Taxonomy Code	Specialty	Notes
207RP0200X	Rheumatology	Specialists who diagnose and manage RA, perform disease activity assessments.
207Q00000X	Internal Medicine	Internists who manage chronic RA and coordinate systemic therapy.
208000000X	Family Medicine	Family physicians who provide longitudinal RA management and follow-up.
363L00000X	Nurse Practitioner	NPs who commonly perform follow-up visits and medication management for RA.
363A00000X	Physician Assistant	PAs who perform routine RA assessments and document encounters in ambulatory settings.

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.	Data not available in the input.	Data not available in the input.

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 outpatient follow-up visit for established RA patients; often used when documenting an additional encounter meeting `M1374` timing.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for more complex medication management or flare visits requiring moderate to high complexity decision making.
`96413`	Chemotherapy administration, intravenous infusion technique; up to 1 hour, for antineoplastic agents (example infusion code often used analogously for infusion services)	Infusion administration codes are documented for biologic treatments; infusion visits often coincide with RA follow-up encounters and scheduling.
`96365`	Intravenous infusion, therapeutic, prophylactic, or diagnostic; initial, up to 1 hour	Used for IV infusions such as certain biologic therapies or steroid infusions performed in outpatient settings alongside RA encounters.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Preventive or counseling services frequently provided during chronic disease management visits for RA patients; billed when applicable.

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