## **What is HCPCS code M1167?**
The Healthcare Common Procedure Coding System (HCPCS) code M1167 is a code used to identify a specific patient status within a quality reporting framework. The code is part of the "Other Services" category in the HCPCS Level II coding system and signifies that a patient was "in hospice or using hospice services during the measurement period."
This code is primarily utilized for quality reporting and performance measurement purposes within healthcare settings. It serves as an exclusion criterion in various quality measures, ensuring that patients receiving hospice care are appropriately accounted for in performance evaluations.
Notably, M1167 is informational only and does not represent a reimbursable service. However, it still plays a crucial role in quality measure reporting by allowing healthcare providers to accurately document patient circumstances that may impact the applicability of certain quality metrics.
## **M1167 documentation requirements**
Since HCPCS code M1167 is primarily used for quality reporting, specifically as a denominator exclusion in certain quality measures, the documentation must substantiate the patient's hospice status. Proper documentation is essential to justify the exclusion of a patient from a particular quality measure, ensuring that the provider's performance data is accurate.
Key documentation elements include:
- A signed and dated hospice election statement in the patient's medical record.
- Physician orders for hospice care.
- A plan of care that confirms the patient is receiving hospice services.
- Documentation from a hospice provider indicating the dates of service.
- Progress notes that reflect the patient's hospice status and the care being provided.
This information is critical for audits and to ensure compliance with the quality reporting program's requirements.
## **M1167 billing requirements**
HCPCS code M1167 is a non-reimbursable code. Its purpose is not for direct payment but for communication and data collection within quality payment programs, such as the Merit-based Incentive Payment System (MIPS).
Important billing considerations include:
- **Reporting on claims**: This code is typically reported on medical claims alongside other services to indicate the patient's hospice status during the measurement period of a specific quality measure.
- **Quality measure specifications**: The use of M1167 is dictated by the specifications of individual quality measures. It is crucial to consult the specific measure's documentation to understand when and how to apply this code. For example, in the MIPS quality measure #493 (Adult Immunization Status), M1167 is used to exclude patients in hospice from the measure's denominator.
- **No direct payment**: It is important to remember that adding M1167 to a claim will not result in any direct payment for the code itself. Its value lies in accurate quality reporting and potential avoidance of negative payment adjustments associated with quality performance.
## **Other relevant codes**
- **M1165**: Patients who use hospice services any time during the measurement period
- **M1166**: Pathology report for tissue specimens produced from wide local excisions or re-excisions
- **M1168**: Patient received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period
- **M1169**: Documentation of medical reason(s) for not administering influenza vaccine (e.g., prior anaphylaxis due to the influenza vaccine)
- **M1171**: Patient received at least one Td vaccine or one Tdap vaccine.
- **M1173**: Patient did not receive at least one Td vaccine or one Tdap vaccine.
Frequently asked questions
