M1265 Cms medical evidence form 2728 for dialysis patients: initial form completed

Billable / valid for submission HCPCS Release 2026Q3

Short description: Cms 2728 completed

Version history

Related codes in M12

• 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%
• M1212 Glycemic status assessment (hba1c or gmi) level is missing, or was not performed during the measurement period
• M1213 No history of spirometry results with confirmed airflow obstruction (fev1/fvc < 70%) and present spirometry is >= 70%
• M1214 Spirometry results with confirmed airflow obstruction (fev1/fvc < 70%) documented and reviewed
• M1215 Documentation of medical reason(s) for not documenting and reviewing spirometry results (e.g., patients with dementia or tracheostomy)
• M1216 No spirometry results with confirmed airflow obstruction (fev1/fvc < 70%) documented and/or no spirometry performed with results documented during the encounter
• M1217 Documentation of system reason(s) for not documenting and reviewing spirometry results (e.g., spirometry equipment not available at the time of the encounter)
• M1218 Patient has copd symptoms (e.g., dyspnea, cough/sputum, wheezing)
• M1220 Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (ai) interpretation documented and reviewed; with evidence of retinopathy

All M12 codes →