M1425 Surgical Care MIPS Value Pathway Medicare Reimbursement | OpenPayer

Summary & Overview

HCPCS M1425: Surgical Care MIPS Value Pathway

HCPCS Level II code M1425 identifies the Surgical Care MIPS Value Pathway, capturing services related to surgical quality reporting and performance measurement. Nationally, value pathway codes are important as they standardize reporting for quality programs that influence provider performance evaluations and program participation under federal and commercial payers. The code matters for hospitals, ambulatory surgery centers, and clinicians engaged in surgical quality improvement.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code's purpose, the typical clinical and operational settings where it applies, and which payers address this reporting construct. The publication outlines benchmarks and policy context related to MIPS value pathways, summarizes clinical implications for surgical practices, and highlights administrative considerations for billing and documentation.

This summary is intended for a national audience of revenue cycle leaders, compliance officers, surgical administrators, and clinicians seeking concise context on HCPCS Level II code M1425 and its role in surgical quality reporting across major commercial payers and Medicare.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1425HCPCS Level IIsurgical careMIPS value pathwayquality reportingambulatory surgeryhospital services

Billing Code Overview

HCPCS Level II code M1425 denotes the Surgical care MIPS value pathway. This code represents services tied to surgical quality reporting and performance measurement within the Merit-based Incentive Payment System (MIPS) value pathway focused on surgical care.

Service type: Quality reporting and performance measurement for surgical care
Typical site of service: Facility and ambulatory surgical settings where surgical quality metrics and reporting activities occur

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is a 58-year-old adult scheduled for a major elective general or specialty surgical procedure enrolled in a Surgical Care MIPS Value Pathway. The patient presents for preoperative assessment in the surgical clinic with a diagnosis such as symptomatic gallbladder disease, colorectal neoplasm, or symptomatic inguinal hernia requiring operative intervention. The clinical workflow begins with preoperative evaluation and optimization (history, physical, relevant labs, imaging, medication reconciliation), informed consent, and scheduling of the operative encounter under an anesthesia plan. On the day of surgery the patient is admitted to the ambulatory or inpatient surgical unit, receives regional or general anesthesia in the operating room (typical site of service: operating room in an acute care hospital or hospital outpatient department; some cases occur in ambulatory surgical centers for less complex procedures), undergoes the definitive surgical procedure, and is transferred to post-anesthesia care unit for immediate recovery. Postoperative care includes inpatient or outpatient follow-up visits, wound checks, pain management, and documentation of surgical quality measures required for the Surgical Care MIPS Value Pathway reporting.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than typically required.

Related Codes

HCPCS-M1388-MELANOMA-RECURRENCE-EXAM

HCPCS M1388: Exam for Recurrence of Melanoma

HCPCS-M1170-INFLUENZA-VACCINE-NOT-RECEIVED

HCPCS M1170: Influenza Vaccine Not Received

HCPCS-M1413-PD-L1-POSITIVE-PRE-FIRST-LINE-IMMUNOTHERAPY

HCPCS M1413: PD-L1 Positive Prior to First-Line Immune Checkpoint Inhibitor Therapy

HCPCS-M1346-PAM-NO-NET-INCREASE-4-12-MONTHS

HCPCS Level II M1346: No Net PAM Score Increase (4–12 Months)

HCPCS-M1379-COLONOSCOPY-10-YEAR-FOLLOW-UP-NOT-RECOMMENDED

HCPCS M1379: 10-Year Colonoscopy Follow-Up Not Recommended, NOS

HCPCS-M1354-SUICIDE-SAFETY-PLAN-NOT-INITIATED-OR-REVIEWED

HCPCS M1354: Suicide Safety Plan Not Initiated or Reviewed

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

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

HCPCS-M1273-SNF-ADMISSION-WITHIN-ONE-YEAR-OF-DIALYSIS-INITIATION

HCPCS Level II M1273: SNF Admission Within One Year of Dialysis Initiation

HCPCS-M1372-GLYCEMIC-STATUS-HBA1C-7-TO-8-PERCENT

HCPCS Level II M1372: Glycemic Status HbA1c 7.0–7.9%

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

HCPCS Level II M1353: Suicide Safety Plan Not Completed

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Taxonomy Code	Specialty	Notes
`207P00000X`	General Surgery	Most common specialty performing a wide range of operative procedures in the Surgical Care MIPS pathway.
`207L00000X`	Colon and Rectal Surgery	Applicable when colorectal procedures are included in the value pathway.
`207RA0000X`	Orthopaedic Surgery	Applicable for musculoskeletal surgical procedures within a surgical MIPS pathway.
`208000000X`	Anesthesiology	Provides anesthesia services, frequently involved during operating room procedures.
`208600000X`	Surgical Critical Care	Provides perioperative ICU management for high-risk surgical patients.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K80.20`	Calculus of gallbladder without cholecystitis, without obstruction	Common indication for elective cholecystectomy under a surgical care pathway.
`K35.80`	Unspecified acute appendicitis	Indication for appendectomy, often managed within surgical quality measures.
`K40.90`	Unilateral inguinal hernia, without obstruction or gangrene, unspecified	Typical diagnosis leading to elective or urgent hernia repair in the surgical pathway.
`C18.9`	Malignant neoplasm of colon, unspecified	Common diagnosis prompting partial colectomy and perioperative quality reporting.
`K57.20`	Diverticulitis of large intestine with perforation and abscess with generalized peritonitis	Example of acute surgical abdomen requiring emergent operative intervention and critical care.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`47562`	Laparoscopy, cholecystectomy; with cholangiography	Commonly performed for symptomatic gallbladder disease as the definitive operative procedure in the surgical pathway.
`44950`	Exploratory laparotomy, exploratory celiotomy with or without biopsy(s)	Performed for diagnosis or definitive management of intra-abdominal pathology in complex surgical care pathways.
`49505`	Repair initial inguinal hernia, age 5 years or older; reducible	Represents a typical general surgical procedure that may be included in the surgical MIPS pathway for hernia repair.
`44140`	Colectomy, partial; with anastomosis	Performed for colorectal disease management and commonly part of a surgical quality reporting bundle.
`99223`	Initial hospital care, typically 70 minutes or more	Represents higher-level initial hospital care often billed by the operating surgeon or service for complex surgical admissions.