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See a sample rate comparisonHCPCS M1116 Fee Schedule
Last Verified: October 2026
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.
The start of an episode of care documented in the medical record
| Key Fact | Detail |
|---|---|
| Service Type | Episode of Care |
| Complexity Level | Low |
National average reimbursement for HCPCS M1116 by major payers:
$71.25
$N/A
$49.42
$0.00
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HCPCS M1116
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See a sample payer proposalHCPCS M1116 vs. Other Episode of Care Codes
The HCPCS M1116 code is part of the Episode of Care services . 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 M1116 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 |
|---|---|---|
| M1115-HCPCS | Low | Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown) |
| M1116-HCPCS | Low | The start of an episode of care documented in the medical record |
| M1117-HCPCS | Low | Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including HCPCS M1116. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the M1116 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.
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