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

Summary & Overview

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

HCPCS Level II code M1376 identifies an additional encounter for a patient with a rheumatoid arthritis (RA) diagnosis occurring at least 90 days before or after another RA encounter within the performance period. Nationally, this code matters for quality measurement and encounter-based reporting frameworks that distinguish separate episodes of care for chronic conditions such as RA. Proper use of M1376 helps differentiate distinct encounters for monitoring disease activity, medication management, and care coordination.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical intent, typical service setting, and implications for encounter classification. The publication provides benchmarks and coding context relevant to performance measurement, outlines how the 90-day timing criterion influences encounter counting, and summarizes policy considerations that affect national reporting workflows. Information on common modifiers and other administrative elements is noted elsewhere in the full publication. Data not available in the input for associated taxonomies, ICD-10 mappings, and related service-line details.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1376HCPCS Level IIrheumatoid arthritisoutpatient encounterquality measurementperformance periodcoding guidance

Billing Code Overview

HCPCS Level II code M1376 describes an additional encounter with an RA diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an RA diagnosis during the performance period. The code captures a separate patient encounter tied to a rheumatoid arthritis (RA) diagnosis that falls outside the 90-day window surrounding another RA encounter within the performance period.

Service type: Follow-up or additional outpatient encounter for RA management
Typical site of service: Ambulatory clinic or outpatient practice setting

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

Clinical & Coding Specifications

Clinical Context

A patient with a documented diagnosis of rheumatoid arthritis (RA) presents for routine disease management. The patient previously had an outpatient visit coded for RA during the performance period; this encounter documents ongoing symptoms, medication tolerance, or treatment response. This billing descriptor for M1376 captures an additional encounter with an RA diagnosis that occurs at least 90 days before or after another RA encounter within the defined performance interval. Typical workflow: the patient checks in at an ambulatory rheumatology clinic or receives a telehealth follow-up; the clinician documents history of present illness, medication review (including DMARDs and biologics), joint exam, disease activity assessment (e.g., RAPID3 or CDAI), and a plan addressing flare management or medication adjustments. Documentation includes the RA diagnosis code, visit date, clinical findings, and any orders (labs, imaging, infusions) that support medical necessity for the encounter.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when services provided during the encounter required substantially greater work than typical for that visit.
`23`

HCPCS M1479: Assessment Impacted by Functional Capacity or Motivation

HCPCS-M1377-COLONOSCOPY-10-YEAR-FOLLOW-UP-INTERVAL

HCPCS M1377: Recommended 10-Year Repeat Colonoscopy Interval

HCPCS-M1227-EVIDENCE-BASED-THERAPY-PRESCRIBED

HCPCS M1227: Evidence-Based Therapy Prescribed

HCPCS-M1430-RETINAL-EXAM-NO-RETINOPATHY-BOTH-EYES-SEVERITY-DOCUMENTED

HCPCS M1430: Retinal Exam, No Retinopathy in Both Eyes with Severity Documented

HCPCS-M1317-COUNSELING-CSP-CONNECTION-OPT-OUT

HCPCS M1317: Counseling on Community Service Provider Connection, Patient Opt-Out

HCPCS-M1298-PREGNANCY-DOCUMENTATION-MEASUREMENT-PERIOD

HCPCS Level II M1298: Documentation of Patient Pregnancy

HCPCS-M1223-GLAUCOMA-PLAN-OF-CARE

HCPCS M1223: Glaucoma Plan of Care Documented

HCPCS-M1291-FRAILTY-AND-DEMENTIA-MEDICATION-DISPENSING-OLDER-ADULTS

HCPCS M1291: Frailty with Dementia Medication Dispensing

HCPCS-LEVEL-II-M1278-ELEVATED-BLOOD-PRESSURE-WITH-DOCUMENTED-FOLLOW-UP

HCPCS Level II M1278: Elevated Blood Pressure with Documented Follow-Up

HCPCS-M1175-DOCUMENTATION-ZOSTER-VACCINE-CONTRAINDICATION

HCPCS Level II M1175: Documentation of Medical Reason for Not Administering Zoster Vaccine

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Taxonomy Code	Specialty	Notes
207RP0000X	Rheumatology	Rheumatologists commonly manage RA disease activity, medication adjustment, and documentation for performance measures.
207L00000X	Internal Medicine	General internists manage chronic RA patients in primary care settings for medication monitoring and comorbidity management.
207Q00000X	Family Medicine	Family physicians provide ongoing RA care, coordinate specialty referrals, and manage routine follow-up.
2084P0800X	Orthopedic Surgery	Orthopedic surgeons may evaluate RA patients for surgical management of joint damage and coordinate perioperative care.
3336C0001X	Clinical Nurse Specialist	Advanced practice clinicians often perform follow-up visits, medication management, and documentation supporting RA encounters.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M06.9`	Rheumatoid arthritis, unspecified	Represents general RA diagnosis used to document encounters for disease monitoring and performance measurement.
`M05.79`	Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or system involvement	Used when seropositive RA involves multiple sites; relevant for disease severity documentation.
`M06.0`	Seronegative rheumatoid arthritis	Used when RA diagnosis is seronegative; relevant to capture variant presentations during follow-up.
`M06.4`	Inflammatory polyarthropathy	Used when multiple joints are inflamed, supporting clinical findings at the encounter.
`M06.8`	Other specified rheumatoid arthritis	Captures less common RA variants documented during additional encounters.

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 for routine RA follow-up encounters documenting symptoms, medication review, and treatment plan; often used when `M1376`-qualifying encounters occur.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for more complex RA visits with moderate to high medical decision making or substantial time spent counseling.
`96365`	Intravenous infusion, initial, for therapy, prophylaxis, or diagnosis; up to 1 hour	Used when biologic infusions (e.g., infliximab) are administered during an RA encounter that may be documented in the performance period.
`73030`	Radiologic examination, shoulder; complete, minimum of two views	Imaging code example for joint assessment when radiographs are ordered to evaluate RA progression or joint damage.
`85025`	Complete blood count (CBC) with automated differential	Common lab test ordered during RA follow-up to monitor medication effects (e.g., cytopenias from DMARDs).
`80061`	Lipid panel	Metabolic monitoring commonly ordered in RA patients, particularly when on corticosteroids or certain DMARDs.

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