HCPCS code M1006 – RA disease activity not assessed

Key takeaways

HCPCS Code M1006 reports that a rheumatoid arthritis patient’s disease activity was not assessed, and no reason was documented.

It is a Performance Not Met numerator code for MIPS Quality ID #177, alongside M1007 (met) and M1008 (assessed at under 50% of encounters).

M1006 carries no separate Medicare payment, so its cost shows up in the clinician’s quality score rather than in reimbursement.

Scoring disease activity with CDAI, DAS28, PAS-II, RAPID3 or SDAI at RA visits is what moves a patient from M1006 to M1007.

Pabau, the practice software we build, can flag deleted codes and missing RA diagnosis codes before a claim leaves the practice.

HCPCS Code M1006: Official descriptor and code classification

HCPCS Code M1006 is the Level II code for “Disease activity not assessed, reason not given.” It reports that an eligible rheumatoid arthritis (RA) patient had no disease activity assessment documented, and the record gives no reason why.

The code belongs to MIPS Quality ID #177, Rheumatoid Arthritis: Periodic Assessment of Disease Activity. The Merit-based Incentive Payment System (MIPS) uses it to check whether clinicians score RA disease activity at half or more of a patient’s RA visits. M1006 is one of three numerator outcomes, and it counts as performance not met.

The Centers for Medicare and Medicaid Services (CMS) maintains the code. The table below sums up its classification, so cross-check it against the current CMS HCPCS release file.

Codes one digit away report different measures. M1003 to M1005 cover tuberculosis screening before biologic therapy, and M1004 is the medical-exception code in that set. Our HCPCS code reference lists the neighboring descriptors side by side.

What HCPCS Code M1006 covers and what it excludes

M1006 applies only to patients in the Quality ID #177 denominator. The measure counts each eligible patient once per performance year, based on the share of RA visits that included a disease activity score.

In scope for M1006 reporting:

• Patients aged 18 and older with two or more RA diagnoses (ICD-10-CM M05.00 to M06.9) at least 90 days apart
• Qualifying outpatient encounters, including office visits billed with 99202-99205 or 99212-99215
• Patients with no disease activity score at their qualifying RA visits, and no documented reason

Excluded from M1006 reporting:

• Patients scored at 50% or more of their RA encounters, who are reported with M1007
• Patients scored at some visits but fewer than half, who are reported with M1008
• Telehealth encounters (modifier GQ or GT, or place of service 02 or 10), which the measure leaves out
• Standalone claims expecting payment, since the code has no price under the Medicare Physician Fee Schedule

The three outcomes split on one question, shown below: was an accepted score recorded, and at how many visits?

Use the AAPC Codify HCPCS lookup to compare descriptors across the M1006-M1014 group before you pick a code.

Documentation requirements for reporting M1006

Even a performance-not-met code needs a record behind it. For M1006, the documentation proves the patient was eligible and shows that no score or reason was charted.

1. Confirm patient eligibility. The record must show an age of 18 or older and two RA diagnoses at least 90 days apart. Check the encounter codes against the current Quality ID #177 specification.
2. Look for an accepted assessment tool. Search each RA visit note for a CDAI, DAS28, PAS-II, RAPID3 or SDAI score. An entry such as “RA stable” does not count as an assessment.
3. Record the supporting diagnosis code. Pair the encounter with an RA code from M05.00 to M06.9, such as M06.9 or M05.9. HIPAA code set standards require a valid diagnosis code on every claim.
4. Note provider credentials. Where CMS specifies an eligible clinician type, document who delivered the visit. Scope-of-practice rules vary by state.
5. Retain for the required period. Medicare generally expects records to be kept for at least seven years from the date of service. State rules may extend that, so confirm with your compliance officer.

ICD-10 diagnosis codes paired with M1006

Quality ID #177 defines its denominator with RA diagnosis codes, so the pairing is narrower than for most M-series codes. The table below shows what qualifies and what to check.

M1006 vs M1007 and M1008: Choosing the right code

Quality ID #177 has three numerator codes, and each reports a different result for the same patient-year. Picking the wrong one misstates the clinician’s performance.

Read each descriptor against the documented visits before you choose. The PGM Billing HCPCS lookup tool offers a free search of CMS data for quick descriptor checks.

Medicare and payer coverage for HCPCS Code M1006

Medicare does not pay for M1006. The code reports quality data rather than a service, so it has no price under the Medicare Physician Fee Schedule. Confirm its current status in the CMS Physician Fee Schedule lookup tool.

Key coverage considerations for billing staff:

• Medicare Part B: If M1006 appears on a claim, expect a $0 allowed amount rather than a denial. The documentation must still support it in an audit.
• MIPS submission: CMS lists Quality ID #177 as a MIPS clinical quality measure (CQM). Most practices submit it through a registry or qualified clinical data registry rather than on the claim.
• Medicaid: State programs vary. Confirm with the state Medicaid agency before reporting M1006 on a Medicaid claim.
• Commercial payers: Commercial insurers may not accept M-series quality codes. Check each payer’s coding policy, or call its provider services line, first.
• Prior authorization: Quality codes don’t need prior authorization, since they report data rather than a service. The visit’s own procedure codes keep their usual authorization rules.

How Quality ID #177 scores M1006

Quality ID #177 is a process measure. Its performance rate is the share of eligible patients reported with M1007, so every M1006 patient pulls the rate down.

The measure follows American College of Rheumatology (ACR) guidance. The ACR recommends a treat-to-target approach, with disease activity measured at most RA encounters. The specification accepts five ACR-recommended tools:

• CDAI: Clinical Disease Activity Index
• DAS28: Disease Activity Score based on a 28-joint count
• PAS-II: Patient Activity Scale-II
• RAPID3: Routine Assessment of Patient Index Data 3
• SDAI: Simplified Disease Activity Index

Specifications are updated every year, and CMS can revise or retire a measure. Download the current #177 specification before each performance period starts.

Common HCPCS Code M1006 claim denial reasons and how to fix them

When M1006 rides on a claim, it gets rejected for a handful of predictable reasons. Most come down to code status, missing documentation or diagnosis pairing.

When you appeal, include the visit notes, the #177 specification page showing the code was active, and the corrected RA diagnosis code. Keeping visit notes and claims in one system makes those records quick to pull.

How Pabau supports accurate M1006 reporting

Tracking #177 by hand means checking every RA visit for a score, then matching the result to M1006, M1007 or M1008. On a spreadsheet, a missed CDAI entry only surfaces when the performance rate comes back low.

Pabau, the practice management platform we build, keeps the visit note and the claim in one patient record. Its claims management software covers the usual M1006 failure points:

• Code validation at entry: HCPCS codes are checked against the current code file, so a deleted code is caught before it triggers a CO-181 rejection.
• Diagnosis pairing checks: A claim missing its RA diagnosis code is flagged before submission, which heads off CO-16 rejections.
• Charting templates: An RA visit form can include a required disease activity score field, so the CDAI or RAPID3 result is charted every time.
• Denial tracking: Rejected claims are grouped by reason code, so a payer that won’t accept M-series codes shows up as a pattern.

The result is fewer M1006 reports to explain, and a #177 rate that reflects the care your clinicians give.

Report quality codes without the spreadsheet

Pabau’s claims management tools validate HCPCS codes, flag missing RA diagnosis codes and track denials by reason code. See how it works for practices reporting MIPS quality codes.

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Conclusion

An M1006 is a documentation problem before it’s a coding problem. If the visit note has no disease activity score, the code is correct, and the clinician’s #177 rate takes the hit.

So fix it upstream. Build an accepted score into every RA visit template, and audit a sample of RA charts each quarter. M1006 then becomes the rare exception, and M1007 becomes the default.

Book a demo to see how Pabau keeps RA visit notes, quality codes and claims in one record for your practice.

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