Policy & Regulation News

Understanding Patient Relationship Codes in MACRA, QPP

Healthcare professionals must familiarize themselves with patient relationship codes included as optional reporting for MACRA's Quality Payment Program.

patient relationship codes macra

Source: Thinkstock

By Sara Heath

- In January 2018, the Centers for Medicare & Medicaid Services (CMS) announced optional reporting for patient relationship codes that would define the purposes for which a clinician treated a patient. Healthcare professionals should opt into using those codes to prepare for eventual mandatory patient relationship coding, according to a recent article in the Journal of AHIMA.

The codes aim to determine how much care management and care coordination cost CMS and how the agency should subsequently distribute payments. Additionally, the codes will inform reimbursement values for clinicians participating in MACRA’s Quality Payment Program (QPP).

“CMS will be considering the utility of patient relationship categories and codes to improve the attribution of resources to clinicians in developing measures of cost, as required by the Medicare Access and CHIP Reauthorization Act (MACRA),” CMS said of the codes.

Patient relationship codes are not a current requirement for 2018 QPP reporting. CMS made reporting optional to help providers ease into the program, but clinicians can expect CMS to make the patient relationship codes a requirement in subsequent years, experts have contended.

Patient relationship codes encompass a variety of healthcare professionals, from specialists to primary care providers. CMS has offered five different codes for providers, each pertaining to a certain type of services.

READ MORE: How Will MACRA Impact Patient Engagement, Care Coordination?

The first code, X1, indicates “continuous/broad services.” This code relates to care with no specific end point and that addresses all of a patient’s health needs. Primary care providers usually fall into this code.

The second code, X2, designates “continuous/focused services.” This code refers to a provider whose specialty expertise is needed over a long period of time for chronic disease management. For example, an endocrine specialist may be instrumental in diabetes care management.

The third code, X3, refers to “episodic/broad services.” This can include a clinician treating all patient health needs during a brief encounter. An internist in a hospital intensive care unit may use the X3 code, for example.

The fourth code, X4, is “episodic/focused services.” Providers who offer brief and specialized care will use this code. For example, an orthopedist performing knee surgery on a patient will use the X4 code.

The final code, X5, is for care “only ordered by another physician.” This pertains to clinicians meeting another physician’s order or referral. For example, a radiologist reading a scan or x-ray ordered by the treating physician will use this code.

READ MORE: How MACRA, MIPS will Help Deliver Patient-Centered Care

Clinicians can use Level II Healthcare Common Procedure Coding System (HCPCS) Modifiers to report these codes, CMS said.

CMS has worked to develop the patient relationship codes to the standards they set today. When first announced in 2016, many healthcare professional societies called into question the methodology for collecting this data, the need for more administrative burden, and the impacts on team-based care that defining patient relationships may have.

In their initial 2016 comments, the American Academy of Family Physicians (AAFP) expressed concern that the administrative burden would not facilitate the benefits CMS had in mind when designing the patient relationship codes.

“The AAFP has grave concerns that the direction CMS is going with the categories it describes is inconsistent with these principles and will simply lead to more ‘administrivia’ for physicians, will not achieve the intended aim of facilitating resource use allocation among physicians and will not lead to better outcomes of care,” AAFP wrote in a letter to then-CMS Administrator Andy Slavitt.

Other organizations, such as the American Society for Clinical Oncologists, stated that the 2016 plans did not include a streamlined data collection system.

READ MORE: More Face-to-Face Interaction Is Key to Patient Engagement

The American Health Information Management Association (AHIMA) stated that patient relationship codes could limit goals for patient-centered and team-based care.

“AHIMA is also concerned 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,” AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, wrote in a letter to Slavitt.

“In a team-based environment, determining the relationship between a patient and a given clinician can be very difficult. The complexity of team-based care needs to be captured in any methodology designed to measure resource use.”

CMS has since refined the patient relationship codes, simplified the reporting mechanism, instituted optional reporting, and held a webinar to educate providers about patient relationship coding. These efforts aimed to ease providers into eventual required patient relationship coding.

Healthcare professionals from AHIMA recommend providers “hard code” their patient relationship codes into the EHR where applicable. This strategy may be most relevant to primary care providers who will usually be suing the X1, “continuous/broad services” code.

Coding may get more difficult for some providers. A specialist may be a key part of chronic disease management and use the “continuous/focused services” code. However, that same specialist may also only be necessary for episodic care, warranting code X2 use. Clinicians in this position must conduct their coding on a case-by-case basis.

As noted above, CMS does not yet require patient relationship code submissions. However, those codes are a MACRA requirement and will eventually be included in the program. Providers should take the opportunity to submit these codes as a learning experience and to better understand the patient relationship coding process.


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