Patient Relationship Codes

January 16th, 2018 - Wyn Staheli, Director of Research
Categories:   Modifiers   Medicare   Claims  
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Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:

  • care episode groups
  • patient condition groups
  • patient relationship categories

Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare claims. In December 2016, they asked for public comment regarding this proposal.
The 2018 Physician Fee Schedule Final Rule included the following table of modifiers to be used to report patient relationships. The “Notes” column is not part of the official Table 27 in the Physician Fee Schedule Final Rule (see References). That information was added from information found in another CMS press release (see References).

Table 27: Patient Relationship HCPCS Modifiers and Categories (with Notes added)

No HCPCS Modifier

Patient Relationship Categories

Notes (see CMS Patient Relationship Categories and Codes in References)

1X X1 Continuous/broad services

“This category could include clinicians who provide the principal care for a patient, where there is no planned endpoint of the relationship. Care in this category is comprehensive, dealing with the entire scope of patient problems, either directly or in a care coordination role.

Examples include, but are not limited to: Primary care, specialists providing comprehensive care to patients in addition to specialty care, etc.”

2X X2 Continuous/focused services

“This category could include a specialist whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time.

Examples include, but are not limited to: A rheumatologist taking care of a patient’s rheumatoid arthritis longitudinally but not providing general primary care services.”

3X X3 Episodic/broad services

“This category could include clinicians that have broad responsibility for the comprehensive needs of the patients, but only during a defined period and circumstance, such as a hospitalization.

Examples include, but are not limited to: A hospitalist providing comprehensive and general care to a patient while admitted to the hospital.”

4X X4 Episodic/focused services

“This category could include a specialist focused on particular types of time-limited treatment. The patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention.

Examples include, but are not limited to: An orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period.”

5X X5 Only as ordered by another clinician

“This category could include a clinician who furnishes care to the patient only as ordered by another clinician. This relationship may not be adequately captured by the alternative categories suggested above and may need to be a separate option for clinicians who are only providing care ordered by other clinicians.

Examples include, but are not limited to: A radiologist interpreting an imaging study ordered by another clinician.”

The Rule states (emphasis added):

We are finalizing our proposal that Medicare claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, should include the applicable HCPCS modifiers in Table 27, as well as the NPI of the ordering physician or applicable practitioner (if different from the billing physician or applicable practitioner). We are finalizing our proposal that for at least an initial period while clinicians gain familiarity, the HCPCS modifiers may be voluntarily reported, and the use and selection of the modifiers will not be a condition of payment. By allowing for a voluntary approach to reporting, we will gain information about the patient relationship codes, allow for a long period of education and outreach to clinicians on the use of the codes, and inform our ability to refine the codes as necessary.

It’s interesting that in the same proposal as the addition of these modifiers, the “Patients Over Paperwork Initiative” was added with the intention of reducing administrative burden. At least, for the time being, this requirement is voluntary and will not affect payments.

CMS stated that with the voluntarily reporting of these modifiers, they “hope the information we learn during this period will help us minimize burden for clinicians in reporting these modifiers.” It should be noted that these are ‘informational’ modifiers and do NOT change the meaning of the procedure codes being reported. They are NOT to be used with quality or resource reporting, just procedures.

One concern cited during the comment period is related to the problem with billing “incident to” services. In response, the ruling states that it allows for multiple clinicians to code for their role during the patient encounter. One benefit to voluntarily reporting is it ensures that issues like this are addressed and resolved before they affect payments.

“Care episodes” were referred to multiple times in the ruling. It would appear that CMS is moving forward with the episode of care model which is more comprehensively discussed in Chapter 4 of the 2018 ChiroCode DeskBook.

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