HCPCS M1392: Documentation of No Examination (Refusal or Lost to Follow-up)

HCPCS Level II code M1392 represents documentation that a patient did not receive an examination due to refusal or being lost to follow-up, and records the clinician's unsuccessful contact attempts by phone, mail, or secure electronic mail. Nationally, accurate use of this code supports administrative transparency, care continuity efforts, and claims clarity when services could not be completed. It matters for provider documentation standards, audit readiness, and consistent reporting across payers.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical and administrative purpose, payer coverage considerations, and where the code is typically used in outpatient and ambulatory settings. The publication outlines benchmarks and common billing practices when available and identifies areas where input data is not provided.

This analysis covers: the operational role of M1392 in documenting refused or incomplete examinations; expected service lines and typical sites of service; and a summary of payer coverage landscape. Data not available in the input is identified clearly where relevant, such as specific payer policy language, associated taxonomies, ICD-10 pairings, and related codes.

Billing Code Overview

HCPCS Level II code M1392 documents the clinician's record of a patient’s reason for not receiving an examination, such as patient refusal or being lost to follow-up. The required documentation must include evidence that the clinician was unable to reach the patient by phone, mail, or secure electronic mail, with at least one contact method documented.

Service type: Documentation of non-examination / outreach attempt

Typical site of service: Outpatient or ambulatory settings where patient contact and scheduling occur, including clinic offices, telehealth/telephone outreach contexts, and administrative follow-up workflows. If additional site-specific guidance is needed, Data not available in the input.

Clinical Context

A patient scheduled for an outpatient clinic visit or procedure does not receive the planned clinical examination because they explicitly decline the exam, fail to present for the appointment, or become unreachable despite attempts. Typical workflow: front-desk staff document missed arrival or patient refusal; clinical staff attempt outreach by telephone, certified mail, and secure electronic messaging per practice policy; the clinician documents the substantive communication attempts, reason for no examination (refusal, lost to follow-up, incarceration, transfer of care, or other documented barrier), and any pertinent history or prior findings available in the chart. The clinician records that at least one method of attempted contact (phone, mail, or secure electronic mail) was used and documents the content and timing of each attempt. This documentation supports billing of HCPCS Level II code M1392 to denote the clinician was unable to perform the exam and provides a medical record justification for the absence of the encounter.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when additional documentation supports substantially greater complexity of related services provided in documentation despite no physical exam (rare for `M1392`).

Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Commonly documents attempts to reach patients for routine clinic visits and documents refusals or no-shows.
`207R00000X`	Internal Medicine	Primary care providers often record inability to perform exams for chronic disease follow-up or acute complaints.
`207P00000X`	Physician Assistant	Mid-level clinicians frequently perform outreach and document refusals or loss to follow-up.
`363A00000X`	Nurse Practitioner	Nurse practitioners in outpatient settings document contact attempts and patient refusal for exams.
`208D00000X`	General Practice	Providers in general practice settings commonly use `M1392` when exam not performed.

Related Diagnoses

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	May be the scheduled E/M service for which the exam was not completed; documentation of attempts and refusal supports billing or modifier use.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Higher-level scheduled visit that may be impacted by patient refusal; documentation justifies any billed services despite no exam.
`99024`	Postoperative follow-up visit, routine; included in global service — no separate charge	May be referenced when a scheduled postop exam was not completed and documentation of inability to examine is required.
`99499`	Unlisted evaluation and management service	Used in rare cases when no standard CPT adequately describes the non-performance of a scheduled procedure and additional documentation is required.
`99050`	Services provided at times or places other than regularly scheduled office hours, or days the office is normally open (e.g., holidays, weekends)	May apply if attempts to reach a patient or documentation occurred outside normal hours and practice bills accordingly.

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Summary & Overview