HCPCS M1055 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | Screening Procedures Anticoagulation Management |
| Complexity Level | Low |
National average reimbursement for HCPCS M1055 by major payers:
$70.12
$N/A
$49.42
$0.00
HCPCS M1055 vs. Other Anticoagulation Management Codes
The HCPCS M1055 code is part of the Screening Procedures services used for Anticoagulation Management. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The HCPCS M1055 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| M1054-HCPCS | Low | Patient had only urgent care visits during the performance period |
| M1055-HCPCS | Low | Aspirin or another antiplatelet therapy used |
| M1056-HCPCS | Low | Prescribed anticoagulant medication during the performance period, history of gi bleeding, history of intracranial bleeding, bleeding disorder and specific provider documented reasons: allergy to aspirin or anti-platelets, use of non-steroidal anti-inflammatory agents, drug-drug interaction, uncontrolled hypertension > 180/110 mmhg or gastroesophageal reflux disease |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including HCPCS M1055. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the M1055 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
Let's review your payer contracts side-by-side with the market.
Bring your top codes (like HCPCS M1055) and we'll show you how you compare in 15 minutes or less.