M1403 PROMIS Surveys HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS M1403: PROMIS Baseline and Follow-Up Survey Documentation

HCPCS Level II code M1403 denotes documentation of both baseline and follow-up PROMIS (Patient-Reported Outcomes Measurement Information System) surveys in the medical record. Nationally, standardized capture of patient-reported outcomes supports value-based care, quality measurement, and clinical decision-making by quantifying symptom burden and functional status over time. Clear coding for PROMIS survey documentation enables consistent reporting and potential linkage to performance programs.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines payer coverage patterns, common billing modifiers, and practical coding context for ambulatory settings where PROMIS instruments are collected.

Readers will find concise benchmarks and operational context for coding PROMIS survey documentation, a summary of common modifiers used with this service, and the clinical settings where M1403 is most applicable. The content addresses how accurate documentation maps to the code and highlights where input data are not available. This national perspective aims to clarify the code's purpose and where it fits into clinical workflows and payer reporting frameworks.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1403HCPCS Level IIPROMISpatient-reported outcomesoutpatientdocumentationambulatory care

Billing Code Overview

HCPCS Level II code M1403 documents patients who have both baseline and follow-up PROMIS surveys recorded in the medical record. This code represents the collection and documentation of patient-reported outcome measures using the PROMIS (Patient-Reported Outcomes Measurement Information System) instruments.

Service Type: Patient-reported outcome measurement and documentation
Typical Site of Service: Outpatient clinics, specialty practices, and other ambulatory settings where PROMIS surveys are administered and charted

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 62-year-old patient with knee osteoarthritis attends an outpatient orthopedics clinic for baseline and follow-up functional assessment. The clinician documents completion of patient-reported outcome measures using the PROMIS (Patient-Reported Outcomes Measurement Information System) instruments at the initial visit to establish baseline pain interference and physical function scores, and again at 6- and 12-week follow-up visits to monitor response to conservative therapy (physical therapy and intra-articular injections). The workflow includes patient completion of electronic PROMIS surveys in the clinic portal or on a tablet, automated scoring and storage in the electronic health record, clinician review and interpretation documented in the progress note, and comparison of baseline and follow-up scores to guide clinical decision-making. Typical staff involved include medical assistants who distribute the survey, front-desk staff who schedule follow-ups, and the provider (orthopedist, physiatrist, or primary care physician) who documents interpretation and the clinical plan based on the PROMIS trend.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when documentation supports substantially greater effort for survey administration/interpretation beyond typical time, with clear justification in the record.

Related Codes

HCPCS-M1340-WHODAS-SDS-INDEX-ASSESSMENT

HCPCS M1340: 12-item WHODAS 2.0 or SDS Index Assessment

HCPCS-M1322-POST-INJECTION-IOP-SCREENING

HCPCS Level II M1322: Post-Injection IOP Screening

HCPCS-M1380-ANTIPSYCHOTIC-MEDICATION-FILL-ADHESION

HCPCS M1380: Antipsychotic Medication Fill — Two or More Prescriptions

HCPCS-M1448-PERSONALITY-DISORDER-DIAGNOSIS-MEASURE

HCPCS M1448: Personality Disorder Diagnosis for Measurement

HCPCS-M1337-ACUTE-PERIPHERAL-VASCULAR-DISEASE

HCPCS M1337: Acute Peripheral Vascular Disease, Acute Care

HCPCS-M1192-ESOPHAGEAL-SQUAMOUS-CELL-CARCINOMA-PATIENT-CLASSIFICATION

HCPCS Level II M1192: Esophageal Squamous Cell Carcinoma, Established Diagnosis

HCPCS-M1168-INFLUENZA-VACCINE-SEASONAL-MEASUREMENT-WINDOW

HCPCS Level II M1168: Seasonal Influenza Vaccination within Measurement Window

HCPCS-M1365-HOSPICE-PALLIATIVE-CARE-ENCOUNTER-SPECIALTY-17

HCPCS M1365: Hospice and Palliative Care Patient Encounter

HCPCS-M1353-SUICIDE-SAFETY-PLAN-NOT-COMPLETED

HCPCS Level II M1353: Suicide Safety Plan Not Completed

HCPCS-M1158-HISTORY-IMMUNOCOMPROMISING-CONDITIONS

HCPCS M1158: History of Immunocompromising Conditions

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Taxonomy Code	Specialty	Notes
`208Z00000X`	Orthopedic Surgery	Common specialty performing baseline and follow-up PROMIS assessments for musculoskeletal conditions.
`207R00000X`	Physical Medicine & Rehabilitation	Frequent user of PROMIS instruments for functional outcome tracking and rehabilitation planning.
`207Q00000X`	Family Medicine	Primary care providers who document PROMIS surveys for chronic disease and pain management follow-up.
`208000000X`	Physical Therapy (PT)	PT providers administer and document PROMIS-based outcomes when integrated into care pathways.
`363A00000X`	Clinical Psychologist	Uses PROMIS measures for mental health domains and patient-reported symptom tracking.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M17.11`	Unilateral primary osteoarthritis, right knee	Common indication for PROMIS baseline and follow-up to track pain and function in knee osteoarthritis.
`M17.12`	Unilateral primary osteoarthritis, left knee	Same as above for left knee symptoms and functional outcome tracking.
`M54.5`	Low back pain	PROMIS instruments are used to quantify pain impact and physical function for back pain treatment monitoring.
`M25.561`	Pain in right knee	Symptom-based diagnosis where PROMIS baseline and follow-up measure treatment response.
`M25.562`	Pain in left knee	As above for left knee presentations.
`R52`	Pain, unspecified	Generic pain diagnosis where PROMIS surveys help characterize severity and monitor change.
`M19.90`	Unspecified osteoarthritis, unspecified site	Use when osteoarthritis is documented without a specified joint; PROMIS assists in functional assessment.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`96127`	Brief emotional/behavioral assessment (e.g., depression inventory) with scoring and documentation, per standardized instrument	Commonly billed alongside PROMIS documentation when brief standardized patient-reported outcome scoring is performed and separately reportable.
`99457`	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month, requiring interactive communication with the patient/caregiver during the month; first 20 minutes	May accompany PROMIS follow-up when remote monitoring and telehealth-based PROMIS collection are part of a chronic care management program.
`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	Used when PROMIS follow-up data are integrated into monthly chronic care management and care coordination documentation.
`99091`	Collection and interpretation of physiologic data digitally stored and/or transmitted by patient and review by physician/other qualified health care professional; 30 minutes	Applicable when PROMIS survey data are collected electronically and require significant physician time to analyze and document trends.
`99397`	Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; older than 65 years	PROMIS assessments may be documented within preventive visits to track function and quality of life in older adults.