Medicare Compliance & Reimbursement

Hint: The modifiers won’t always be voluntary, CMS warns.

Since MACRA mandated the Quality Payment Program (QPP), Medicare providers have been struggling to keep up with all the requirements, measures, and changes impacting their Part B reimbursement. And a recent CMS transmittal recommends practices prepare themselves for patient relationship coding changes down the pike, sooner rather than later.

Context: Back in 2016, CMS unveiled its idea to use HCPCS Level II modifier codes to explain the patient-provider relationship in the Merit-Based Incentive Payment System (MIPS). The agency followed up with its traditional comment period and stakeholder tweaking. Finally, CMS outlined the five patient relationship categories and codes (PRCs) in the 2018 Medicare Physician Fee Schedule (MPFS), making them voluntary under the MIPS Cost category. (See Medicare Compliance & Reimbursement, Vol. 43, No. 22).

Now: Though PRC reporting is still optional, Medicare Administrative Contractors (MACs) are advised to accept and manage claims with “the modifiers [X1-X5] for the patient relationship categories and codes (PRC),” indicates Change Request (CR) 11259. However, CMS directs both MACs and clinicians that “a subsequent system/implementing CR will be released at a later date when the PRC becomes mandatory and is incorporated into Cost measures,” the agency says.

Though the modifiers don’t impact Medicare reimbursement and beneficiaries right now, Part B providers may want to start using them anyway. “Reporting of these modifiers will be mandatory in the near future, and CMS advises clinicians to participate for easier transition,” informs CR 11259.

Review CR 11259 at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2300OTN.pdf.

Check Out the Codes to Know

The PRCs aim to help CMS “distinguish the relationship and responsibility of a clinician with a patient at the time of furnishing an item or service, thereby facilitating the attribution of patients and episodes to one or more clinicians for purposes of Cost measurement,” relates an agency FAQ on the modifiers and categories.

Providers can self-identify and explain their patient relationships with these five code options:

• 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 with no planned endpoint to the relationship…)
• X3 (Episodic/broad services: for reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient that is limited to a defined period and circumstance such as a hospitalization…)
• X4 (Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; 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 (Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories…).

Consider These Examples

If you’re wondering why CMS didn’t make the modifiers mandatory back in 2018, the agency insists it has two good reasons for the introductory voluntary period.

Clinicians need “to gain familiarity with the categories and experience submitting the codes,” according to CMS guidance. Moreover, the optional ramp up allows the feds “to collect data on the use and submission of the codes for analyses to inform the potential future use of these codes in cost measure attribution methodology in the Quality Payment Program [QPP],” notes CR 11259.

If you’re still wondering how to use these modifiers, consider these provider examples from a CMS webinar on PRCs:

• X1 represents initial contact by providers looking at the “entire scope of patient problems,” CMS says. A primary care physician would report X1 as his patient relationship code.
• Specialists, whose “expertise” is needed for treatment, would submit the X2 modifier. An “orthopedist managing osteoarthritis before knee replacement” would use this PRC, CMS advises.
• A MIPS-eligible clinician whose care has time limits would append the X3 modifier. CMS suggests that a very general relationship surrounds this PRC. A scenario might include simply “a hospitalist managing a patient in the hospital,” the agency explains.
• Time constraints also define the specialty-specific X4 modifier. For example, if a Part B beneficiary presents to the emergency department (ED) and that ER physician addresses the patient’s condition, she would use X4 to describe the patient-provider relationship.
• X5 refers to a patient relationship “ordered” by another physician. So if you are a radiologist and asked to look at a CT scan, you’d use the X5 modifier, CMS materials suggests.

Resource: Find the MIPS patient relationship code FAQs at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Patient-Relationship-Categories-and-Codes-webinar-FAQ.PDF.