What providers should know about CMS patient relationship category codes

AHIMA offers advice for using the new codes, created as part of the Quality Payment Program, which have begun being reported voluntarily this year.
By Mike Miliard
04:26 PM
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What providers should know about CMS patient relationship category codes

In an effort to get a better handle on how (and how often) providers are interacting with their patients, MACRA's Quality Payment Program called for the creation of a set of categories and codes enabling providers to define clinician-patient relationships.

The codes, which aim to give Medicare officials perspective on cost attribution, have been reported on a voluntary basis since the beginning of 2018, but could become more important to understand as the journey toward value-based reimbursement continues.

Hospital IT leaders would be smart to familiarize themselves with the way the new codes could affect coding and EHR workflow.

The codes describe patient-provider encounters, such as the frequency with which certain patients see specific physicians, to "define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing an item or service,” according to CMS.

"For the time being, the assignment of these codes is voluntary to soften the learning curve, and the use and selection of the modifiers will not yet be a condition of payment," Mary Butler wrote in the Journal of AHIMA.

But Butler makes clear that it would behoove hospitals and practices – "any setting where Medicare claims are generated" – to familiarize themselves with the new codes.

Essentially, there are five categories, coded X1 through X5. In order, they define: Continuous/Broad Services; Continuous/Focused Services; Episodic/Broad Services; and "Only as Ordered by Another Physician."

"Code selection could be harder in some specialties than others," says Butler. "For example, in primary care, the services provided are continuous or ongoing, since that’s the nature of primary care. Those practices can 'hard code' the modifiers into the electronic health record so that it appears automatically."

But certain specialties might need to take a different approach, for instance, "a lot of cardiologists render primary care depending on their relationship with the patient," she writes. "On other occasions, a cardiologist might provide treatment to patients on an ongoing basis but only for a patient’s heart failure. In other cases, a cardiologist might read a diagnostic study but not see that patient face-to-face, requiring a different modifier."

Butler notes that CMS "has long been using carrots and sticks in an effort to get providers on board with new billing and reimbursement changes, so providers are assuming that they’ll eventually be penalized for failing to use the new relationship categories and codes – though again CMS has not indicated if or when that would happen."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com