M1385 HCPCS: Documentation & Reimbursement | OpenPayer

Summary & Overview

HCPCS M1385: Documentation of Reasons for Missed Second PAM Survey

HCPCS Level II code M1385 designates documentation of patient reasons for not completing a second Patient Activation Measure (PAM) survey, such as when less than four months elapse between baseline and intended follow-up. Nationally, standardized capture of why follow-up assessments are missed supports care continuity measurement, quality reporting, and administrative clarity for programs tracking patient activation and self-management readiness. The code applies across ambulatory and care-management settings where PAM assessments are used.

This analysis covers common national payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for using M1385, typical service settings, and the kinds of documentation elements referenced by the code. The publication summarizes benchmarking considerations, coding practice implications, and any notable policy or billing guidance that affects consistent use of the code. Where payer-specific data are not available, the report notes that input data were not provided.

Intended audiences include billing and coding professionals, care managers, quality improvement teams, and health policy analysts seeking concise guidance on the code’s purpose and operational use in national programs tracking patient activation survey workflows.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1385HCPCS Level IIpatient activationPAM surveydocumentationcare managementoutpatientquality measurement

Billing Code Overview

HCPCS Level II code M1385 documents the patient-reported reasons for not completing a second PAM survey, for example when the interval between the baseline Patient Activation Measure (PAM) assessment and the intended follow-up is less than four months. This code captures structured documentation explaining why a follow-up PAM assessment was not performed.

Service type: Documentation of survey follow-up status and reasons for non-completion
Typical site of service: Outpatient clinics, primary care settings, care management programs, home health follow-up contacts, or other ambulatory visit contexts where PAM assessments and follow-up surveys are managed

Clinical & Coding Specifications

Clinical Context

A patient enrolled in a chronic care quality improvement program has a baseline Patient Activation Measure (PAM) assessment documented. A planned follow-up PAM survey was scheduled within the program timeline to evaluate changes in self-management and activation. At follow-up, the patient was not assessed because the interval since baseline was less than four months, the patient declined contact, the patient was unreachable after multiple outreach attempts, or the patient had an intervening acute event that precluded survey completion. Typical workflow: care manager reviews the registry to identify patients due for PAM follow-up, attempts outreach by phone and secure message, documents reasons for non-completion in the chart, and bills ancillary documentation using HCPCS Level II code M1385 to indicate the second PAM survey was not completed with reasons recorded. Typical site of service is outpatient clinic or telehealth/care-management remote encounter. Typical patient scenario: a 68-year-old patient with type 2 diabetes and heart failure enrolled in a CCM/telehealth program completed baseline PAM; follow-up scheduled at three months but program policy requires four months minimum, so the nurse documents the reason for missing the second PAM (less than four months since baseline) and other outreach outcomes before billing M1385.

Coding Specifications

Modifier	Description	When to Use

HCPCS M1480: Assessment Validity Impacted by Patient Capacity or Motivation

HCPCS-M1221-DILATED-RETINAL-EXAM-NO-RETINOPATHY

HCPCS M1221: Dilated Retinal Exam with Interpretation, No Retinopathy

HCPCS-M1427-BONE-SCAN-MEDICAL-JUSTIFICATION

HCPCS Level II M1427: Documentation of Medical Reason for Bone Scan

HCPCS-M1458-PATIENT-DIED-PERFORMANCE-PERIOD

HCPCS M1458: Patient Died Prior to End of Performance Period

HCPCS-M1334-POST-OPERATIVE-EYE-ACUTE-PVD-ENCOUNTER

HCPCS M1334: Post-Operative Eye Encounter for Acute Posterior Vitreous Detachment

HCPCS-M1223-GLAUCOMA-PLAN-OF-CARE

HCPCS M1223: Glaucoma Plan of Care Documented

HCPCS-M1502-PODIATRY-MIPS-VALUE-PATHWAY

HCPCS M1502: Podiatry MIPS Value Pathway

HCPCS-M1289-TOBACCO-USER-NO-CESSATION-INTERVENTION

HCPCS M1289: Tobacco User Without Cessation Intervention

HCPCS-M1368-INFECTIOUS-DISEASE-PREVENTION-TREATMENT-HEPATITIS-HIV

HCPCS M1368: Prevention and Treatment of Infectious Disorders including Hepatitis C and HIV

HCPCS-M1335-DOCUMENTATION-PATIENT-NO-FOLLOW-UP-REASON

HCPCS M1335: Documentation of Reasons for Not Having Follow-Up Exam

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Taxonomy Code	Specialty	Notes
`252Y00000X`	Registered Nurse	Common provider performing outreach, assessment, and documentation for PAM follow-up.
`173900000X`	Care Coordinator / Case Manager	Performs registry management, outreach, and documentation of reasons for non-completion.
`207Q00000X`	Family Medicine Physician	Oversees chronic care programs and signs documentation as needed.
`207R00000X`	Internal Medicine Physician	Manages patients in chronic disease programs and may review or authorize documentation.
`353L00000X`	Clinical Social Worker	May perform patient outreach and document barriers to assessment completion.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`E11.9`	Type 2 diabetes mellitus without complications	Diabetes patients commonly enrolled in activation and self-management programs using PAM assessments.
`I50.9`	Heart failure, unspecified	Patients with heart failure are often part of chronic care management and activation assessment programs.
`F32.9`	Major depressive disorder, single episode, unspecified	Depression can affect patient activation and the ability to complete follow-up assessments.
`Z71.89`	Other specified counseling	Counseling and activation interventions documented alongside PAM assessments.
`Z79.4`	Long term (current) use of insulin	Reflects chronic disease management context where PAM is used to measure self-management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`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	Often performed alongside PAM assessments as part of ongoing care management; documentation of missed PAM may be recorded during CCM encounters.
`99439`	Chronic care management services, additional 20 minutes (list separately in addition to code for primary CCM)	Used when additional time is required for outreach and documentation beyond the baseline CCM time.
`99457`	Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a month; first 20 minutes	May be billed in programs that include remote monitoring where PAM is part of engagement and documentation of non-completion occurs during RM management.
`99458`	Remote physiologic monitoring treatment management services, each additional 20 minutes	Used when extra time is expended for outreach and documentation related to missed PAM assessments.
`98960`	Education and training for patient self-management for new or established patient; face-to-face, 30 minutes	Used when PAM follow-up is completed later and triggers self-management training; related in the clinical workflow following documentation of non-completion.

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