Conquer Patient Relationship Categories and Codes

Posted on 13 Jun, 2018 |comments_icon 0|By Elizabeth

In the 2018 Medicare Fee Schedule rule, CMS reviews MACRA patient relationship categories and codes, their development and timelines, and provides details for the initial claims-based reporting of the relationship categories and codes to CMS. These patient relationship categories and codes 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.

Background: MACRA requires that CMS post the operational list of Patient Relationship Categories and Codes by April 2017 and that the codes be included by clinicians on all Medicare claims, as determined appropriate by the Secretary, beginning January 1, 2018. These have been outlined in section 1848, Collaborating with the Physician, Practitioner, and Other Stakeholder Communities to Improve Resource Use Measurement, under a new subsection (r)—and requires the development of care episode and patient condition groups, in addition to group classification codes. To satisfy the purpose of patient and/or episode attribution to one or more clinicians, it requires:

  • Categories and codes must define and distinguish an applicable practitioner’s relationship to and responsibility for each patient when an item or service is furnished to the patient.
  • Categories shall include different potential practitioner-patient relationship types.
  • Categories shall reflect various potential responsibility types.
  • Categories shall capture the frequency with which the practitioner delivers care to the patient.

The following operational list of patient relationship categories in May 2017 as required under section 101(f) of MACRA include:

  1. Continuous/broad services: For reporting services by clinicians who provide the principal care for a patient with no planned endpoint of the relationship. Services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role.

Examples:primary care services and specialists providing comprehensive care to patients in addition to specialty care

  1. 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.

Example: a rheumatologist taking care of the patient’s rheumatoid arthritis longitudinally but not providing general primary care services

  1. 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.

Example: a hospitalist providing comprehensive and general care to a patient while the patient is admitted to the hospital

  1. Episodic/focused services: For reporting services by specialty focused clinicians who provide time-limited 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.

Example: an orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period

  1. 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.

Example: a radiologist interpretation of an imaging study ordered by another clinician.

Use Modifiers to Report Patient Relationship Codes

CMS has long been planning for the use of procedure code modifiers for the reporting of patient relationship codes. In December 2016, they also sought comment on the use of Level II Healthcare Common Procedure Coding System (HCPCS) Modifiers for this work. CMS received public comments which indicated that Current Procedural Terminology (CPT®) Modifiers would be the best way to operationalize the reporting of patient relationship codes.

CMS works with the American Medical Association’s (AMA) CPT® Editorial Panel, which is responsible for maintaining the CPT® code set. CMS submitted a CPT® code application that was rejected in June 2017, as the CPT® Editorial Panel preferred to wait until the proposed modifiers were finalized before issuing Category I CPT® codes. CMS proposed using HCPCS modifiers shown in Table 9-1.

Proposed HCPCS Modifier Patient Relationship Categories
X1 Continuous/Broad Services
X2 Continuous/Focused Services
X3 Episodic/Broad Services
X4 Episodic/Focused Services
X5 Only as Ordered by Another Clinician


Don’t miss: In the 2018 Final Rule, CMS finalized Level II HCPCS modifiers for use on claims to indicate these patient relationship categories, which stipulates that these HCPCS modifiers may be reported voluntarily by clinicians associated with these patient relationship categories beginning January 1, 2018. They also finalized that the use and selection of the modifiers will not be a condition of payment.

Takeaway: By allowing for a voluntary approach to reporting, CMS believes they will gain information about the patient relationship codes, allow for a long period of education and outreach to clinicians on the use of the codes, and update their ability to refine the codes as necessary.

Check out: Find out how you can get more involved! Get current information about episode groups, Patient Relationship Categories and Codes, and offer your input at Check out the “Give Feedback on MACRA” page, too.

Learn More

Don’t let piecemeal information or complex, barely-intelligible MACRA guidelines torpedo your earnings. Gear up for payment rewards now with TCI’s MACRA Quality Measures Guide 2018.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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