Relationship Status: Best Practices for Reporting New Patient Relationship Category Codes

By Mary Butler

They are a reliable staple of women’s magazines everywhere, and seem likely to be until the end of time: articles that coach women on the proper way to have a “defining the relationship” conversation with someone they are dating. These delicate conversations, “DTRs,” are a crucial way to determine whether one is in a casual relationship or a serious, marriage-potential relationship—if the magazines are to be believed. Some couples put off this discussion, while others embrace it early on.

Either way, DTR talks are stressful. But once initiated, both parties can move on from uncertainty and onto a path that (hopefully) brings both people happiness in the end. In love as in life, being able to label or define something that once seemed ambiguous is powerful.

As the healthcare industry transitions from fee-for-service reimbursement to rewarding efficient care, it has become even more important that healthcare data is well defined. In that sense, the Centers for Medicare and Medicaid Services (CMS) is the empowered party demanding the DTR conversation take place within a healthcare treatment context, while providers and their attendant coding professionals are responsible for providing an answer—or in this case, a code. The Medicare Access and CHIP Reauthorization Act’s (MACRA) Quality Payment Program required the establishment of categories and codes to define clinician/patient relationships for use in determining Medicare cost attribution. Coding professionals (physician practice coders) began reporting these patient relationship categories and codes on January 1, 2018 on a voluntary basis. Patient relationship categories and codes were developed 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.

“In essence, CMS is interested in identifying the cost of managing chronic and acute care,” says Faith McNicholas, CM, RHIT, CPC, CPCD, PCS, CDC, manager, coding and reimbursement, advocacy and policy, at the American Academy of Dermatology. “If one references the value-based modifier reporting, CMS had insinuated that they would reward those providers that saved the money on care for the Medicare trust fund. As you may recall, some providers received a decent bonus during the value-based modifier program. But the message was clear—the more you save and provide quality but necessary care, [the more] you get rewarded.”

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. There will be no impact to the CY 2018 physician payments under the Physician Fee Schedule. CMS will use this voluntary period to educate providers and stakeholders about this change, as well as collect data for validity and reliability testing of the codes before their potential use in the attribution methodology for cost measures, according to a CMS webinar.1

AHIMA members who work in hospitals, for physician practices, for dental surgeons, for optometrists, for chiropractors, or in any setting where Medicare claims are generated, are responsible for understanding these new categories/codes—and they will be involved with helping physicians understand them as well. With this in mind, it’s important for coding professionals as well as physicians to understand why these new categories/codes were developed, what they are, how providers use them, and documentation best practices for code assignment.

Patient Relationship Codes and Categories

As prescribed by CMS, there are five patient relationship categories, which are operationalized through Level II HCPCS modifier codes.4

Code

Category

Description

X1

Continuous/Broad Services

Covers services by clinicians providing principal care with no planned end date. Services in this category deal with the entire scope of a patient’s problems (i.e., primary care clinicians; specialists also providing primary care). 

X2

Continuous/Focused Services

For services by clinicians whose expertise is needed for ongoing management of a chronic disease over a long period of time (i.e., an endocrinologist managing diabetes; a speech language pathologist treating swallowing problems).

X3

Episodic/Broad Services

For services by clinicians who have broad responsibility for comprehensive needs, limited to a defined period and circumstance such as a hospitalization (i.e., hospitalists managing an inpatient; an intensivist managing an ICU patient).

X4

Episodic/Focused Services

For services by specialty-focused clinicians providing time-limited care. The patient has an acute or chronic problem treated with surgery, radiation, or another time-limited treatment (i.e., a surgeon performing a one-time joint replacement; an anesthesiologist doing post-op monitoring).

X5

Only as ordered by another physician

For services by a clinician furnishing care to a patient as directed by another clinician (i.e., an audiologist conducing hearing and balance test; a neurologist conducting an EMG).

‘It’s Just One More Thing’

Other changes that have accompanied the shifting reimbursement system and code set updates have tended to make providers feel squeezed by every change, and adding patient relationship modifiers is no different. Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC, an independent coding consultant, says physicians are used to assigning evaluation and management (E&M) codes, but they still haven’t quite mastered diagnosis codes. The prospect of adding yet another code can feel daunting.

“Most physicians now have an EMR [electronic medical record] they’re [using to choose] the codes and the modifiers before they close out that encounter. Then depending on the practice, some have a coder that looks it over before it’s submitted,” Huey says. “[In most cases] they don’t have a coder looking at each encounter and assigning codes for each encounter… It’s a burden [for coders] because they think ‘It’s just one more thing to teach physicians to do.’”

As for where on the claim form a physician or coding professional should place the modifier, CMS temporarily answered that question in a webinar on the patient relationship modifiers. Rose Do, MD, clinician lead at Acumen, LLC and co-presenter of a recent CMS webinar discussing the relationship categories and codes, noted that CMS hasn’t clarified how many of the lines it could be reported on.

“My understanding is that it’s a modifier—[HCPCS] Level II modifier that can be reported at the claim line level. So, I think for a given clinician, that they have a PRC [patient relationship code], they can just report the one where it summarizes the overall relationship with the patient. And that should be enough,” Do states.2

Using the Codes

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.

The American Academy of Dermatology’s McNicholas, who helped write AHIMA’s response to CMS when the codes were first proposed, tries to emphasize the benefits of physicians knowing exactly who they are treating.3 “As a user and patient, I see the positive in encouraging our providers to move in this direction. Yes, this is another modifier we have to use. But, I would like to know how much my care costs compared to if I saw Dr. X down the street. Would patient care be competitively cheap if there was transparency?” McNicholas says. “All this data CMS will collect will eventually be available publicly and that will help patients become informed consumers of their healthcare dollars.”

Additionally, providers who report these codes and follow the rules should, in the long run, see a positive impact on their Merit-based Incentive Payment Program (MIPS) scores and more accurate reimbursement—or the reimbursement a provider deserves given their level of care provided to patients, Huey says.

Among AHIMA’s criticisms of the codes when they were first proposed was that they were not sufficiently well-defined to produce accurate and meaningful data. Additionally, AHIMA expressed concern that “an approach for resource use attribution that involves identification of the relationship between a patient and an individual clinician is not aligned with team-based care. In a team-based environment, determining the relationship between a patient and a given clinician can be very difficult.”

CMS addressed these concerns in its webinar in February and provided some clinical scenarios to illustrate how to use the codes. The webinar presenters used the fictional example of a Patient Khan who develops actinic keratosis (AK) and sees a dermatologist for treatment with cryotherapy. The visits with the dermatologist span two visits to treat the AK. This would require a patient relationship code of X4, Episodic/Focused Services. This same patient also has encounters with an orthopedic surgeon a few months later for a joint replacement. The patient sees this physician for pre- and post-operative checkups as well as the actual surgery. A patient relationship code of X4 also applies in this encounter.

“As we can see, the dermatologist has an interaction that spans two visits. It’s an episodic type of length, and the treatment is involving mainly the actinic keratosis. It’s not really broad-based care. It’s very focused on the skin condition. So this would be exemplified as episodic focused or X4. As you can see, the orthopedic surgeon, a different type of clinician, could also utilize the same patient relationship code. In this situation, it’s again—there’s some post-operative checkups, the actual surgery, making this an episodic example. And given that it’s focused on the joint replacement itself, it’s also a focused relationship. So this would be an X4,” explains Do, the webinar co-presenter.

Huey says physicians don’t need to document any differently to ensure proper code assignment, so that’s not a worry for providers or coding professionals. “If somebody were to read the whole record and look at that and then audit, they’re going to be able to see what the physician’s relationship is with that patient. They’ll see some sort of notation, such as ‘I’m sending them back to Dr. So-and-So to manage their diabetes.’ That’s evident in the record,” Huey says. “Their documentation doesn’t need to change—they’re just deciding which modifier is already supported by that documentation.”

Code selection could be harder in some specialties than others. 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 (EHR) so that it appears automatically. But, Huey says, it can get trickier in certain specialties, such as cardiology, since a lot of cardiologists render primary care depending on their relationship with the patient. 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.

“Think about what relationship is with a patient today and choose the correct modifier,” Huey advises.

Time to Practice

Definitions matter—in romance and coding. And in both of these worlds, the more challenges that are met with conversations, the easier it will be to improve outcomes. Huey says she’s been met with “deer in the headlights” looks from physicians when presented with talk of new codes to learn. One practice administrator even refused to let her talk to physicians about the new codes until CMS makes them mandatory. But denying these codes exist may not be the best approach. HIM experts say the voluntary reporting period offers a good chance to practice with the new codes and work out any issues or answer any questions long before mistakes can actually impact reimbursement.

Notes

  1. Centers for Medicare and Medicaid Services. “Quality Payment Program Patient Relationship Categories and Codes.” Webinar. February 21, 2018. 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.
  2. Centers for Medicare and Medicaid Services. “Quality Payment Program Patient Relationship Categories and Codes.” Webinar transcript. February 21, 2018. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Patient-Relationship-Categories-and-Codes-transcript-2-21-18.pdf.
  3. American Health Information Management Association. “Patient Relationship Categories and Codes.” Letter to Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services, August 15, 2016. http://bok.ahima.org/PdfView?oid=301853.
  4. Centers for Medicare and Medicaid Services. “Quality Payment Program Patient Relationship Categories and Codes.” Webinar.

Mary Butler (mary.butler@ahima.org) is associate editor at the Journal of AHIMA.


Article citation:
Butler, Mary. "Relationship Status: Best Practices for Reporting New Patient Relationship Category Codes." Journal of AHIMA 89, no.6 (June 2018): 16-19.