Are your clinicians reporting patient relationship codes on their Medicare Part B claims? The HCPCS Level II modifiers are voluntary this year, making it a good time to get in practice.

What Is the Purpose of Patient Relationship Categories and Codes?

The Medicare Access and CHIP Authorization Act of 2015 (MACRA) requires the Centers for Medicare & Medicaid Services (CMS) to implement patient relationship categories and codes to attribute patients and episodes to one or more clinicians for purposes of cost measurement. Clinicians are not required to include the applicable patient relationship codes on claims, yet, but it’s just a matter of time — CMS says it will implement the reporting requirement through the standard rulemaking process.

Patient relationship categories define and distinguish the relationship and responsibility of a clinician with a patient at the time of service. This allows CMS to track the cost of a patient’s care provided my multiple clinicians. In the future, CMS may consider using patient relationship category codes for attribution of cost measures such as those used in the Merit-based Incentive Payment System (MIPS).

Keeping that in mind, it behooves clinicians to make sure CMS collects accurate and comprehensive data.

What Are Patient Relationship Categories and Codes?

There are five patient relationship categories and associated codes, finalized in the 2018 Medicare Physician Fee Schedule, for use in the voluntary reporting period, which began Jan. 1, 2018:

• X1 Continuous/Broad Services
• X2 Continuous/Focused Services
• X3 Episodic/Broad Services
• X4 Episodic/Focused Services
• X5 Only as ordered by another clinician

These are HCPCS Level II modifier codes that clinicians can report on Medicare Part B claims to identify their patient relationships.

How Do the Categories Differentiate Patient Relationships?

Differentiating between the patient relationship codes is simple enough:

Report X1 for comprehensive care provided by a clinician who is dealing with the patient’s entire scope problems, with no planned endpoint for that care. For example, primary care providers generally provide continuous, broad services for their established patients.

Report X2 for a specialist’s ongoing management of a patient’s chronic disease or a condition that needs to be managed and followed for a long time. For example, a rheumatologist providing ongoing care for a patient’s rheumatoid arthritis is a continuous, focused service.

Report X3 for a clinician who has a broad responsibility for the comprehensive needs of a patient for a defined period and circumstance. For example, a hospitalist who provides comprehensive and general care to a hospital inpatient is providing an episodic, broad service.

Report X4 for time-limited care provided by a specialty-focused clinician. For example, an orthopedic surgeon performing a knee replacement surgery is an episodic, focused service.

Report X5 for patient care ordered by a clinician that isn’t captured by the ordering clinician. For example, a radiologist’s interpretation of an imaging study ordered by another clinician would be billed with modifier X5.

How Do Clinicians Report and Document Patient Relationships?

Clinicians may report their patient relationships on CMS-1500 claims by adding the appropriate modifier code to each claim line (item 24D). Clinicians may report different patient relationships for separate items and services billed on the same claim. There are no requirements for the sequencing of the patient relationship modifier relative to other modifiers.

The big question is whether clinicians will document their patient relationships, or if coders and billers will have to determine the appropriate modifiers for every service based on clinician documentation.