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Patient Relationship Categories

By Melody Mulaik

Patient relationship categories and modifiers have been around for a number of years, but their utilization is not mandatory, and it is unclear when and if this will occur.

The Medicare Access and CHIP Reauthorization Act (MACRA) requires CMS to develop patient relationship categories to classify the patient’s relationship with the physician or practitioner who is providing the service. These categories are used to evaluate the cost of care by linking resource use to the physician or practitioner who is responsible for it. This information will be crucial in developing new value-based payment systems.

CMS has defined five relationship categories that describe the type of services the clinician is providing to the patient – continuous/broad services, continuous/focused services, episodic/broad services, episodic/focused services, and diagnostic services requested by another clinician.

Of these five categories it is anticipated that the two that will be utilized by radiologists will be X4 or X5. (See Table 1.)

Radiologists whose practice is limited to diagnostic imaging will report most or all of their services with modifier X5 (Diagnostic services requested by another clinician). An example of this modifier is “the radiologist’s interpretation of an imaging study requested by another clinician.” Interventional radiologists’ services, on the other hand, will likely qualify for modifier X4 (Episodic/focused services).

The MPFS Final Rule states that claims submitted by physicians and practitioners for dates of service on or after January 1, 2018, should include the applicable HCPCS modifier. However, the use of the modifiers will not be a condition of payment during the initial learning period. CMS has not stated how long the learning period will last or when the use of the modifiers will become mandatory.

As you utilize these modifiers, pay close attention to the total number of modifiers that you are using for a given study and the order they are listed. Payment modifiers should always precede those which are informational, so ensure proper placement of modifiers when submitting the claim. Once the threshold of five (5) modifiers is reached, a “99” must be appended as a modifier at the line-item level in block 24D and the individual modifiers listed in block 19 on the claim form.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.

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