M1492 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS Level II M1492: Patient Did Not Report a Fall

HCPCS Level II code M1492 denotes documentation that a patient did not report a fall. This code is used in clinical assessments to record fall history and supports care planning, risk stratification, and quality reporting. Nationally, consistent use of such encounter-level documentation codes matters for population health monitoring, preventive care workflows, and accurate encounter records.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical context, typical settings where it is applied, and how it fits into assessment workflows. The publication summarizes benchmarking and reporting considerations, notes where data is not available in the input, and highlights policy and billing context relevant to providers and administrators.

The content provides practical reference material: what the code represents, where it is commonly used, and which major payers are relevant for coverage and submission. It is intended for health system coders, compliance officers, and clinicians involved in documentation and quality measurement.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareM1492HCPCS Level IIfall assessmentrisk assessmentoutpatientdocumentationquality reportingbilling code

Billing Code Overview

HCPCS Level II code M1492 is used to indicate patients who did not report a fall. The code reflects documentation of a patient's fall history during an assessment when the patient denies any falls.

Service type: Risk assessment / fall history documentation
Typical site of service: Ambulatory clinic or other outpatient assessment settings

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is a community-dwelling older adult seen in primary care or a post-acute clinic for routine fall-risk screening where the patient explicitly reports no falls since the prior visit. The clinician documents a history review, focused functional assessment, medication review, and targeted examination (gait, balance, orthostasis) to determine ongoing fall risk despite no reported falls. The workflow includes: initial intake noting “no falls,” clinician-performed focused assessment, reconciliation of high-risk medications, brief mobility testing (e.g., timed up-and-go or gait observation), counseling on home safety and activity, and documentation of the encounter tied to the billing code M1492 for patients who did not report a fall. Typical visit locations include primary care clinics, geriatrics clinics, home health assessments, outpatient rehabilitation clinics, and telehealth visits where the provider confirms absence of falls and completes fall-risk-related evaluation and counseling.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable E/M service by the same physician on the same day as a procedure	Use when a distinct evaluation or management service is provided in addition to fall-risk screening for a patient who reports no falls.

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HCPCS-M1370-REHABILITATIVE-SUPPORT-MUSCULOSKELETAL-CARE-MIPS

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HCPCS-M1332-INADEQUATE-INITIAL-EVALUATION-FOLLOW-UP

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians commonly perform fall-risk screening and document no falls.
`207R00000X`	Internal Medicine	Internists provide routine preventive assessments including fall-risk evaluation when no falls are reported.
`207L00000X`	Geriatric Medicine	Geriatricians focus on fall-risk assessment, medication review, and functional evaluation in older adults.
`2084P0800X`	Physical Therapy	Physical therapists perform mobility and balance assessments and document no-fall status during outpatient or home visits.
`163W00000X`	Home Health Service Provider	Home health clinicians evaluate fall risk and environment when patients report no falls.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`R29.6`	Repeated falls	Often used when falls are reported; not typically assigned when patient reports no falls but relevant for negative screening context.
`Z91.81`	History of falling	Used when past falls are documented; relevant to fall-risk evaluation even if no recent falls are reported.
`R26.2`	Difficulty in walking, not elsewhere classified	Common comorbidity prompting fall-risk screening despite absence of reported falls.
`M62.81`	Muscle weakness (generalized)	Muscle weakness increases fall risk and is often assessed when patients report no falls.
`I95.1`	Orthostatic hypotension	Orthostatic symptoms are assessed during fall-risk evaluation even when patients report no falls.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99395`	Periodic comprehensive preventive medicine reevaluation and management of an individual (18–39 years)	Used for age-appropriate preventive visits where fall-risk screening and documentation of no falls may be part of the visit.
`99397`	Periodic comprehensive preventive medicine reevaluation and management of an individual (65 years and older)	Commonly used in annual wellness visits for older adults where fall-risk assessment and documentation of no falls are performed.
`97112`	Therapeutic procedure, one or more areas, each 15 minutes (neuromuscular re-education)	Performed by physical therapists when balance or gait training is initiated after screening indicates risk despite no reported falls.
`92548`	Treatment of aphasia; with pre- and post-testing and individual treatment	Not typically related; Data not available in the input.
`G0438`	Annual wellness visit, first visit	Used for initial Medicare Annual Wellness Visits where fall-risk screening and documentation of no falls may be conducted.

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