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Reporting the HCPCS Level 11 Modifiers of the Patient Relationship Categories and Codes, Implementation Date: August 12, 2019

During this initial period of implementation, reporting of the PRC on claims is voluntary. In the future, it will be mandatory and tied to cost measures preceded by rulemaking. As of January 1, 2018, Medicare Part B Merit-Based Incentive Payment System (MIPS)-eligible clinicians may now report their patient relationships on Medicare claims using the PRC codes.

Below is the description of the PRC Code Modifiers X1, X2, X3, X4 and X5:

  • X1 - Continuous/Broad services = For reporting services by clinicians who provide the principal care for a patient, with no planned endpoint of the relationship
  • X2- 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.
  • X3 -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.
  • X4 - 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.
  • X5 - 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.

The Centers for Medicare & Medicaid Services (CMS) has several goals for the voluntary reporting period:

  • For clinicians to gain familiarity with the categories and experience submitting the codes
  • To collect data on the use and submission of the codes for analyses to inform the potential future use of these codes in cost measure attribution methodology in the Quality Payment Program

CR Transmittal Number: R2300OTN


INDUSTRY NEWS TAGS: CMS


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