If you haven’t heard of patient relationship codes or don’t remember the term, then you’re not alone.

MACRA or the Medicare Access and CHIP Reauthorization Act of 2015 required the development of these patient relationship categories which aim to 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.

In a nutshell it gives CMS a better idea of where and to whom to attribute beneficiary costs.

The MACRA patient relationship codes are Healthcare Common Procedure Coding System or HCPCS Level II modifier codes that clinicians report on claims to identify their patient relationship categories.

There are five specific modifier codes that can be reported. They are X1 through X5 we will give you a brief explanation for each. You can also find in-depth information by doing a search for Patient Relationship Categories and Codes.


X1 Services by primary care or specialty clinicians who provide the principal care for a patient, with no planned endpoint.
X2 Services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition for a long time.
X3 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.
X4 Services by specialty focused clinicians who provide time-limited care.
X5 Services by a clinician who furnishes care to the patient only as ordered by another clinician.

Let’s take a moment to talk about who can report and how.

The patient relationship categories and codes are currently in a voluntary reporting period, which began January 1, 2018. As of this date, the following clinicians may report patient relationships: physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. CMS may expand this list to include additional clinicians through rulemaking for future years.

How long is the voluntary reporting period?

CMS has not established the duration of the voluntary reporting period, but anticipates it will include at least calendar year 2018 and 2019. The goals of this period are to educate clinicians on proper coding of patient relationships and to collect initial data for further study. The data collected will be used to conduct validity and reliability tests on the patient relationship categories and codes before consideration of their potential future use in the attribution methodology for cost measures. CMS may adjust the length of the voluntary reporting period based on factors including clinicians’ adoption of the codes, data analysis findings, and stakeholder feedback. Mandatory reporting would be established through rulemaking, and until then reporting will be voluntary.

During the voluntary reporting period, claims will be paid regardless of whether and how the patient relationship codes are included, and CMS will work with clinicians to educate them about the proper use of these codes.

How do clinicians report their patient relationships?

Clinicians may report their patient relationships on claims by adding one of the patient relationship codes to each claim line in the same way that modifier codes are submitted on each claim line for each service rendered. This method of reporting patient relationships allows clinicians to report different patient relationships for separate items and services billed on the same claim.

How should clinicians capture changes in their patient relationships over time?

The patient relationship categories and codes are designed to be flexible to accommodate changes in clinician-patient relationships over time. This flexibility is achieved through clinicians reporting different relationships as needed on individual claims for the same patient over time. Clinicians should think of the patient relationship categories as describing a discrete clinical encounter. CMS recognizes that acute conditions can become chronic and that chronic conditions can have acute exacerbations. Nonetheless, determining whether a clinician-patient relationship is episodic or continuous depends on a given point in time when the claim is being submitted for the item or service furnished by the clinician.

For example, in the case where a chronic condition has an acute exacerbation, the managing clinician would report:

  • Continuous/focused on claim lines with items and services provided for the long-term management of the chronic condition X2
  • Episodic/focused on claim lines with items and services provided for treatment of the acute flare X4

The example demonstrates how relationship codes allow clinicians to report multiple patient relationships on a single claim. A clinician may report distinct patient relationship categories for various services listed on a claim for the same patient.

Finally, when and how can patient relationship categories be used in the attribution methodology for MIPS episode-based cost measures?

CMS believes experience and analysis is needed before incorporating the patient relationship categories and codes into episode-based cost measures. The patient relationship categories may be considered for use in the episode-based cost measurement methodology after reliability and validity tests are conducted. CMS anticipates collecting several years of claims data to allow sufficient time for clinicians to gain familiarity with correctly coding their patient relationships and for CMS to understand the attribution potential of these codes. Over this time, CMS plans to engage in extensive education and outreach to help clinicians understand the categories and codes and their proper use. Once the necessary reliability and validity analyses have been conducted and clinicians have become acclimated to the use of these codes, CMS may consider their use in attribution for cost measures.

MACRA provides for the patient relationship categories and codes to be used to facilitate the attribution of patients and episodes to clinicians. Although CMS may work with clinicians to explore incorporating the patient relationship categories into the MIPS cost performance category and the Quality Payment Program in future years, the cost measures that have been finalized to date and those currently under development do not require patient relationship reporting to properly measure clinicians’ quality and resource use. This is to say we don’t know when they will be required but getting started now can ease the transition in the coming years.

If you have questions or need assistance with any part of the Quality Payment program please contact us at 844.205.5540 or techassist@qsource.org.