M1398 PROMIS Surveys HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II M1398: PROMIS Baseline and Follow-up Survey Documentation

HCPCS Level II code M1398 represents documentation that a patient has both baseline and follow-up PROMIS (Patient-Reported Outcomes Measurement Information System) surveys recorded in the medical record. This code is used to capture longitudinal collection of patient-reported outcome measures, which are increasingly important for tracking functional status, symptom burden, and treatment response across specialties. Nationally, standardized PROM capture supports value-based care initiatives, quality measurement, and population health management.

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 purpose, typical sites of service, and the kinds of benchmarks and policy considerations relevant to payer coverage and documentation practices. The publication outlines how M1398 fits into outpatient workflows for specialty and rehabilitation clinics, summarizes common modifier usage where applicable, and notes where input data were not provided.

This analysis is intended to inform clinical administrators, billing professionals, and policy stakeholders about the operational and policy context for M1398, including documentation expectations and the broader relevance of PROMIS-based measures in national payment and quality frameworks. Data not available in the input are indicated where relevant.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1398HCPCS Level IIPROMISpatient-reported outcomesoutpatient servicesdocumentationquality measurementvalue-based care

Billing Code Overview

HCPCS Level II code M1398 documents patients who have both baseline and follow-up PROMIS surveys recorded in the medical record. The service represented is the collection and documentation of patient-reported outcome measures (PROMIS) at baseline and at a subsequent follow-up. The typical site of service is outpatient clinical settings where longitudinal patient-reported outcome assessment is integrated into care (for example, specialty clinics, rehabilitation clinics, and outpatient practices).

Clinical & Coding Specifications

Clinical Context

A middle-aged adult patient with a chronic musculoskeletal condition (for example, knee osteoarthritis or chronic low back pain) presents to an outpatient orthopedic clinic for initiation of a treatment program. The practice documents baseline patient-reported outcomes using the PROMIS (Patient-Reported Outcomes Measurement Information System) instrument prior to treatment initiation. The patient completes the baseline PROMIS survey electronically in the clinic portal or on a tablet at check-in. The clinician documents the baseline score in the medical record and discusses results with the patient as part of shared decision-making.

At a scheduled follow-up visit (routine follow-up, post-procedure visit, or periodic outcome assessment), the patient completes a follow-up PROMIS survey. The provider documents the follow-up score, compares it to the baseline, and records interpretation in the medical record. Documentation includes date and method of administration, the specific PROMIS domain(s) assessed (for example, Physical Function, Pain Interference, or Depression), numerical scores, and any clinical actions taken based on change in scores (for example, therapy modification or referral). Billing for M1398 is reported when both baseline and follow-up PROMIS surveys are documented in the medical record as part of outcome measurement and care management.

Typical site of service: outpatient clinic, ambulatory surgery center pre/post-op clinic, or rehabilitation clinic. Typical clinicians involved: orthopedic surgeons, physical medicine and rehabilitation physicians, primary care physicians, physical therapists, and behavioral health clinicians when applicable.

Coding Specifications

Modifier	Description	When to Use

HCPCS Level II M1254: Patient Deceased on Home Health Survey Contact

HCPCS-M1244-PATIENT-PERCEIVED-PROVIDER-BEST-INTERESTS

HCPCS M1244: Patient-Reported Provider Best-Interest Response

HCPCS-M1458-PATIENT-DIED-PERFORMANCE-PERIOD

HCPCS M1458: Patient Died Prior to End of Performance Period

HCPCS-M1299-INFLUENZA-IMMUNIZATION-ADMINISTERED-OR-PREVIOUSLY-RECEIVED

HCPCS M1299: Influenza Immunization Administered or Previously Received

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

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

HCPCS-M1442-TELEHEALTH-ENCOUNTER-VISIT-VIRTUAL-CARE

HCPCS Level II M1442: Telehealth Encounter / Virtual Visit

HCPCS-M1418-COVID19-VACCINATION-MEDICAL-CONTRAINDICATION

HCPCS M1418: COVID-19 Vaccination Not Up to Date Due to Medical Contraindication

HCPCS-M1301-TOBACCO-CESSATION-INTERVENTION

HCPCS M1301: Tobacco Cessation Intervention for Identified Tobacco Users

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

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

HCPCS-M1158-HISTORY-IMMUNOCOMPROMISING-CONDITIONS

HCPCS M1158: History of Immunocompromising Conditions

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Taxonomy Code	Specialty	Notes
`207X00000X`	Orthopedic Surgery	Orthopedic surgeons commonly request and document PROMIS baseline and follow-up scores for musculoskeletal outcomes.
`2084P0800X`	Physical Medicine & Rehabilitation	PM&R physicians use PROMIS instruments for functional outcome tracking and rehabilitation planning.
`207Q00000X`	Family Medicine	Primary care physicians monitor symptom burden and function over time using PROMIS measures.
`173C00000X`	Physical Therapist	Physical therapists administer and record PROMIS physical function or pain interference domains during therapy episodes.
`2082P0800X`	Pain Medicine	Pain specialists utilize PROMIS pain domains to assess treatment response and guide pain management.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M17.11`	Unilateral primary osteoarthritis, right knee	PROMIS physical function and pain interference domains track outcomes for knee osteoarthritis treatment and interventions.
`M54.5`	Low back pain	PROMIS instruments assess function and pain impact in patients with chronic low back pain.
`M16.11`	Unilateral primary osteoarthritis, right hip	Hip osteoarthritis patients use PROMIS physical function scores to monitor response to conservative or operative care.
`M25.551`	Pain in right hip	Symptom-specific diagnosis for which PROMIS pain and function domains are useful to quantify severity and treatment effect.
`G89.29`	Other chronic pain	PROMIS pain interference and related measures are frequently used to quantify chronic pain burden and guide management.
`F32.9`	Major depressive disorder, single episode, unspecified	PROMIS depression domain can be used alongside physical health measures when mood impacts perceived function.
`Z79.899`	Other long term (current) drug therapy	Used when ongoing medication therapy (for example, chronic opioid or disease-modifying therapy) is present and outcomes are monitored with PROMIS.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97110`	Therapeutic exercises to develop strength and endurance, range of motion and flexibility	Often performed alongside PROMIS assessments in rehabilitation visits to document functional interventions and correlate with patient-reported outcomes.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, low to moderate complexity	Common E/M code billed for clinic visits where baseline and follow-up PROMIS surveys are documented and discussed.
`99457`	Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication	May be used when PROMIS surveys are collected remotely and drive remote care management activities.
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory), per standardized instrument	Used for brief PROMIS-derived screening or when a short standardized behavioral measure is administered in conjunction with PROMIS domains.
`G0438`	Annual wellness visit, initial visit	Wellness or preventive visits may include baseline PROMIS measures for functional status when initiated during a comprehensive exam.

`22`	Increased procedural services	Use when work required to document or interpret PROMIS surveys is substantially greater than typical for the service.
`23`	Unusual anesthesia	Not commonly used for this service; included for completeness when anesthesia is required for concurrent procedure during same encounter.
`52`	Reduced services	Use when only partial administration or limited documentation of PROMIS surveys occurs compared to the full service.
`53`	Discontinued procedure	Use when PROMIS administration is attempted but abandoned due to patient intolerance or other clinical reasons.
`54`	Surgical care only	Use when another provider documents PROMIS scores but the reporting clinician provided only the surgical portion of care (rare applicability).
`55`	Postoperative management only	Use when the provider reporting PROMIS documentation is providing only postoperative follow-up care.
`56`	Preoperative management only	Use when PROMIS baseline assessment was performed solely as preoperative management by a different provider.
`62`	Two surgeons	Use when two surgeons of different specialties share responsibility and both document PROMIS-related outcome assessments.
`AS`	Ambulatory surgical center facility	Use to report facility status when service is furnished in an ambulatory surgical center.
`QK`	Medical direction of two, three, or four ancillary personnel	Use when a qualified provider medically directs allied health staff who administer PROMIS surveys under direction.

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