M1255 HCPCS code: Patients who have another reason for visiting the clinic [not prenatal or postpartum care] and have a positive pregnancy test but have not established the clinic as an ob provider (e.g., plan to terminate the pregnancy or seek prenatal services elsewhere)
M1255 is the HCPCS Level II code for patients who have another reason for visiting the clinic [not prenatal or postpartum care] and have a positive pregnancy test but have not established the clinic as an ob provider (e.g., plan to terminate the pregnancy or seek prenatal services elsewhere). Its Medicare coverage code is C (Carrier judgment): Coverage is decided by the Medicare contractor (MAC) case by case.
Code details
| Field | Value |
|---|---|
| Section | M codes — Medical services and quality measures |
| Coverage code | C — Carrier judgment |
| Pricing indicator | 00 — Not separately priced by Medicare |
| BETOS category | Z2 |
| Added | 2024-01-01 |
| Last action effective | 2024-01-01 |
What changed for M1255
- 2024-01-01: M1255 added to HCPCS Level II
- Next scheduled CMS quarterly update (HCPCS and DMEPOS fee schedule): 2027-01-01
Frequently asked questions
What is HCPCS code M1255?
M1255 is the HCPCS Level II code for patients who have another reason for visiting the clinic [not prenatal or postpartum care] and have a positive pregnancy test but have not established the clinic as an ob provider (e.g., plan to terminate the pregnancy or seek prenatal services elsewhere). Short descriptor: "Pts w/ othr rsn vst,+prg tst".
Does Medicare cover M1255?
Coverage code C — Carrier judgment. Coverage is decided by the Medicare contractor (MAC) case by case.
Related M12 codes
- M1200 — Ace inhibitor (ace-i) or arb therapy prescribed during the measurement period
- M1201 — Documentation of medical reason(s) for not prescribing ace inhibitor (ace-i) or arb therapy during the measurement period (e.g., pregnancy, history of angioedema to ace-i, other allergy to ace-i and arb, hyperkalemia or history of hyperkalemia while on ace-i or arb therapy, acute kidney injury due to ace-i or arb therapy), other medical reasons)
- M1202 — Documentation of patient reason(s) for not prescribing ace inhibitor or arb therapy during the measurement period, (e.g., patient declined, other patient reasons)
- M1203 — Ace inhibitor or arb therapy not prescribed during the measurement period, reason not given
- M1204 — Initial (index visit) numeric rating scale (nrs), visual rating scale (vrs), or itchyquant assessment score of greater than or equal to 4
- M1205 — Itch severity assessment score is reduced by 3 or more points from the initial (index) assessment score to the follow-up visit score
- M1206 — Itch severity assessment score was not reduced by at least 3 points from initial (index) score to the follow-up visit score or assessment was not completed during the follow-up encounter
- M1207 — Patient is screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety
- M1208 — Patient is not screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety
- M1209 — At least two orders for high-risk medications from the same drug class, (table 4), without appropriate diagnoses
- M1210 — At least two orders for high-risk medications from the same drug class, (table 4), not ordered
- M1211 — Most recent glycemic status assessment (hba1c or gmi) level > 9.0%
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Next steps
- Run a reimbursement report for a device billed under M1255
- Watch M1255 for fee, coverage and descriptor changes
- Build a full Medicare revenue model for M1255
Sources: CMS HCPCS Level II release October 2025; CMS DMEPOS fee schedule; CMS NCCI MUE tables; CMS Medicare utilization (physician and DME supplier files); CMS Medicare Coverage Database articles. Fees are Medicare allowables, not commercial rates. Not billing or legal advice.