Patient relationship category codes

Use of these code modifiers is voluntary for the time being but is expected to become mandatory in the near future.


The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requires the establishment and use of classification codes for patient relationship categories. The purpose of patient relationship categories and codes is to facilitate the attribution of patients and care episodes to clinicians who serve patients in distinct roles as part of the assessment of the quality and cost of care.

Image by Thinkstock
Image by Thinkstock

Specifically, the patient relationship categories are intended to define and distinguish the relationship and responsibility of a clinician with a patient at the time of service, facilitate the attribution of patients and episodes of care to one or more clinicians, and allow clinicians to self-identify their patient relationships.

CMS solicited public comments and worked with the American Medical Association's Current Procedural Terminology (CPT) Editorial Panel to develop these patient relationship category code modifiers. The list of patient relationship categories and codes was finalized in the 2018 Physician Fee Schedule final rule. For now, the use of these code modifiers is in a voluntary reporting period, with the expectation that they will soon be required.

All clinicians can now report their patient relationships on their Medicare claims. The goals of this voluntary reporting period are to educate clinicians about proper coding of patient relationships and to collect data for validity and reliability testing. Whether and how these codes are reported will not affect Medicare payment.

There are five patient relationship categories in the list, each with a Level II Healthcare Common Procedure Coding System (HCPCS) modifier code (Table).

Hospitalists and intensivists, whether they are the attending physician of record or a medical consultant for a surgical attending, would be expected to use code modifier X3 (episodic broad services), being responsible for overall care and coordination for a patient during an acute hospitalization.

If a hospitalist sees a patient in an outpatient, postdischarge follow-up setting for a brief period of time without assuming long-term care responsibility, the code modifier to use is X4 (episodic focused services), since he or she would be providing services for a specific condition or treatment for a definite period of time.

For example, suppose a patient admitted for acutely decompensated heart failure can't schedule an appointment with his primary care physician after discharge for two weeks. The hospitalist sees him once for an outpatient follow-up visit three days postdischarge, then releases him to his primary care physician for ongoing care.

Hospitalists who do not see any patients in an outpatient, postdischarge follow-up setting can “hard-wire” all electronic claims with the X3 modifier for inpatient evaluation and management (E/M) codes. On the other hand, hospitalists who do see some patients in an outpatient, postdischarge follow-up setting for a brief period of time without assuming long-term care responsibility would have to would have to set up their systems to append X3 to E/M inpatient codes and X4 to outpatient E/M codes.

In summary, CMS has developed these code modifiers to facilitate the attribution of patients and care episodes to clinicians in distinct roles. Use of these code modifiers is voluntary for the time being but is expected to become mandatory in the near future. Hospitalists should begin using these modifiers to gain experience and implement processes in preparation for them becoming mandatory.