2025 HCPCS code M1292
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Other Services - Frailty and Advanced Illness Other Services Feed
Identifies patients aged 66+ with frailty and advanced illness, meeting specific criteria for program measurement.
Medical necessity is established through proper documentation of the patient's age, frailty, and qualifying advanced illness encounters, demonstrating that the criteria for M1292 are met.This code is typically used for reporting and quality measurement within specific healthcare programs and not for direct reimbursement.
Documentation in the medical record must show the patient is 66 or older, has at least one claim/encounter for frailty, and meets the criteria for advanced illness encounters (either one acute inpatient visit or two separate outpatient/observation/ED/non-acute inpatient visits on different service dates) within the measurement period or the prior year.
In simple words: This code tracks patients 66 or older who are frail and have a serious illness.It's used for tracking purposes in specific health programs, not for billing individual services.
This HCPCS Level II code (M1292) designates patients 66 years or older who have at least one documented claim/encounter for frailty during the measurement period.Additionally, they must have either one acute inpatient encounter with an advanced illness diagnosis or two outpatient/observation/ED/non-acute inpatient encounters (on different dates of service) with an advanced illness diagnosis within the measurement period or the preceding year."Advanced illness" refers to a significantly debilitating condition requiring complex management. This code is supplemental for data collection and performance measurement; it does not replace codes for procedures/services rendered.
Example 1: A 72-year-old patient with documented frailty presents to the emergency department with pneumonia (advanced illness). This encounter, along with prior documentation of frailty, satisfies the criteria for M1292., An 80-year-old patient with multiple outpatient visits for chronic heart failure (advanced illness) and a documented history of frailty meets the criteria for code M1292, assuming at least two separate outpatient encounters occurred within the defined period., A 68-year-old patient admitted to the hospital for a hip fracture (advanced illness) who has a documented history of frailty fulfills the requirements for code M1292.
Medical record documentation must include: (1) Patient age (≥66 years); (2) Evidence of at least one encounter for frailty; (3) Documentation of either one acute inpatient encounter or two separate outpatient/observation/ED/non-acute inpatient encounters for advanced illness within the measurement period or the year before, with diagnoses specifying the advanced illness condition.
** This code is intended for data collection and performance measurement within specific healthcare programs.It is not a billable code in the traditional sense and should not be used as a substitute for codes representing specific procedures or services.
- Payment Status: Active
- Specialties:Geriatrics, Internal Medicine, Cardiology, Pulmonology, other specialties involved in managing advanced illness
- Place of Service:Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital, Office, Observation