Get a Glimpse at Potential 2018 MACRA Coding Requirement for Patient Relationship Category

MACRA provider patient relationship categories

There could be new HCPCS modifiers coming your way as part of MACRA to identify patient relationship categories. If the term “patient relationship categories” is new to you, then here’s a brief overview.

MACRA requires patient relationship categories and codes as part of an effort to improve resource attribution to clinicians. So there’s a look at cost and the clinician’s relationship to the patient (short-term, long-term, etc.).

Timeline: CMS is supposed to post the operational list of patient relationship categories and codes by April 2017. The current plan is for clinicians to start using the codes on all Medicare claims beginning Jan. 1, 2018.

Dig In to the Patient Relationship Category Details

After an initial round of draft categories and comments, CMS posted new categories for consideration:

1. Continuous/broad: This is the category for clinicians responsible for comprehensive, principal care with no defined endpoint. The care may be direct or in a care coordination role.

  • CMS examples: Primary care provider or specialist also responsible for a patient’s comprehensive care

2. Continuous/focused: A specialist who works with a patient for a long time falls under this category.

  • CMS example: Rheumatologist treating only a patient’s rheumatoid arthritis

3. Episodic/broad: This category covers clinicians providing comprehensive care for a defined period.

  • CMS example: Hospitalist

4. Episodic/focused: A specialist providing time-limited treatment, like surgery or radiation, is in this category. The condition treated may be acute or chronic.

  • CMS example: Orthopedic surgeon performing a knee replacement and postop care

5. Only as ordered by another clinician: This is the category for those who provide care only when ordered by other providers.

  • CMS example: Radiologist interpreting image ordered by another clinician

Check Out Possible Role of HCPCS Modifiers

CMS also has to determine how to identify patient relationship categories on claims from physicians and practitioners, and this is where the potential new HCPCS modifiers come in. These modifiers are the leading contender because they offer several advantages:

  • There’s already a process in place for creating new HCPCS modifiers
  • CMS systems can accept HCPCS modifiers
  • A modifier appends directly to the service code, allowing for more precision in data collection.

How About You?

How have you been getting to know MACRA? Do you think there’s a better option than HCPCS modifiers to identify relationship categories?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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