Introduction to Patient Relationship Categories and Codes

Introduction to Patient Relationship Categories and Codes

In 2017 MACRA revoked the Sustainable Growth Rate (SGR) formula and introduced the Quality Payment Program; a payment program based on quality of care and not quantity. The Quality Payment Program assesses clinicians on a range of performance categories including the cost category.

MACRA requires the development of patient relationship categories and codes for possible use in the methodology for the cost measures. A fact sheet on the cost category can be found at https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-Cost-Performance-Category-Fact-Sheet.pdf

Specifically, the patient relationship categories are intended to:

  • Define and differentiate the relationship and responsibility of a clinician with a patient at the time of furnishing an item or service
  • Facilitate the attribution of patients and episodes to one or more clinicians

There are 5 relationship categories and codes available for reporting. These were finalized in the CY2018 PFS final rule and are operationalized through Level II HCPCS modifier codes. The use of these codes by MIPS eligible clinicians became voluntary beginning 1/1/2018. During the voluntary period, Medicare claims will not be affected. The object of the voluntary period is to educate clinicians and stakeholders about proper coding of patient relationships and to collect data for validity and reliability testing before reporting becomes mandatory.

The table below illustrates the five patient relationship codes, their category and a brief description for each:

Code Category Description
X1 Continuous/Broad

Services

Clinician providing comprehensive care for a patient with no planned endpoint of the relationship
X2 Continuous/Focused

Services

Specialist providing ongoing management of a specific chronic

disease or condition over an indefinite period

X3 Episodic/Broad

Services

Clinician responsible for overall care and coordination for a

patient during an acute hospitalization or inpatient

rehabilitation

X4 Episodic/Focused

Services

Clinician providing services for a specific condition or treatment

for a definite period of time

X5 Only as Ordered by

Another Clinician

Clinician furnishing services to provide information to another

clinician without directly initiating a treatment plan

To learn more about these codes, their use and clinical scenarios please visit:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Patient-Relationship-Categories-and-Codes-slides-2-21-18.pdf