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Reporting Patient Relationship Categories and Codes

Reporting Patient Relationship Categories and Codes

Under MACRA legislation passed in 2015, Patient Relationship Categories and Codes (PRC) were established to help attribute patients and care episodes to physicians and other clinicians for measuring cost, particularly in the Quality Payment Program. Beginning in 2020, voluntarily reporting PRC on claims may count toward the Improvement Activity performance category of MIPS for the 2020 performance year. 

Beginning January 1, 2018, MIPS-eligible providers could report PRC on claims on a voluntary basis using the following HCPCS Level II code modifiers:

  • X1 – Continuous/Broad services = For reporting services by clinicians who provide the principal care for a patient, with no planned endpoint of the relationship.
  • X2- Continuous/Focused services = For reporting services by clinicians 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.
  • X3 -Episodic/Broad services = For reporting services by clinicians who have broad responsibility for the comprehensive needs of the patients, that is limited to a defined period and circumstance, such as a hospitalization.
  • X4 – Episodic/Focused services = For reporting services by specialty focused clinicians who provide timelimited care. The patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention.
  • X5 – Only as Ordered by Another Clinician = For reporting services by a clinician who furnishes care to the patient only as ordered by another clinician. This patient relationship category is reported for patient relationships that may not be adequately captured in the four categories described above. 

While reporting PRC continues to be voluntary, these codes will not affect Medicare reimbursement and have no impact on beneficiaries. However, the Centers for Medicare and Medicaid Services (CMS) hopes that this initial implementation period will give clinicians risk-free experience submitting the codes and help them gain familiarity with the categories. 

CMS also is collecting data on the use and submission of the codes to inform the potential future use of these codes. For instance, allowing the use of PRC codes to count toward the Improvement Activity performance category of MIPS for the 2020 performance year was included in the 2020 proposed Medicare Physician Fee Schedule, which should be finalized by November.

For more information about Patient Relationship Categories and Codes, check out MLN Matters Number: MM11259, “Reporting the HCPCS Level II Modifiers of the Patient Relationship Categories and Codes.” You can also read the CMS fact sheet, “CMS Patient Relationship Categories and Codes,” which includes examples of how each of these modifiers might be used by various clinicians.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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