MIPS-Eligible Clinicians: Learn More about Reporting Patient Relationship Categories

CMS recently released a Medicare Learning Network (MLN) Matters article about reporting Patient Relationship Categories and Codes (PRC) on Medicare claims.

Voluntary Reporting Period

As of January 1, 2018, Medicare Part B Merit-based Incentive Payment System (MIPS)-eligible clinicians may report patient relationships on Medicare claims using the PRC codes. While this will be mandatory in the future, reporting of the PRC codes is voluntary during this initial period of implementation.

CMS advises clinicians to participate in this voluntary reporting period to gain familiarity with the categories and experience submitting codes. CMS will review data on the use and submission of the codes to consider their potential future in cost measure attribution methodology in the Quality Payment Program.

PRC Code Modifiers

  • X1 – Continuous/Broad services: For clinicians who provide the principal care for a patient with no planned endpoint of the relationship.
  • X2 – Continuous/Focused services: For clinicians whose expertise is needed for the ongoing management of a chronic disease or condition.
  • X3 – Episodic/Broad services: For clinicians who have broad responsibility for the comprehensive needs of patients that is limited to a defined period and circumstance, such as a hospitalization.
  • X4 – Episodic/Focused services: For specialty focused clinicians who provide time-limited care. The patient has a problem that will be treated with a time-limited intervention, such as surgery or radiation.
  • X5 – Only as Ordered by Another Clinician: For clinicians who provide care to patients only as ordered by other clinicians.

CMS has proposed in the 2020 QPP Notice of Proposed Rulemaking that voluntary reporting of the codes would count towards the Improvement Activity performance category of MIPS for the 2020 performance year. More information will be available if this provision is confirmed in the final rule later this year.

Please note: Whether and how the codes are reported on claims will NOT affect Medicare reimbursement and have no impact on beneficiaries.

For More Information

To learn more about requirements, scenarios and reporting of these code modifiers, as well as how CMS plans to use PRC reporting for cost measurement, visit the CMS website. To learn more about the Quality Payment Program, visit: https://qpp.cms.gov