APMA News - July/August 2019 - 29

Reimbursement
The CPT claim lines for a patient who receives an evaluation and management for diabetic neuropathy may look like:
CPT 99213 - X2
In the above examples, X4 was chosen for the plantar fasciitis patient because plantar fasciitis is typically a time-limited
pathology, whereas X2 was selected for the diabetic neuropathy encounter because diabetic neuropathy typically requires
ongoing management over a longer period of time.
As CMS attributes costs to providers, the importance of
establishing the most appropriate doctor-patient relationship
is evident. We now have an opportunity to report the nature
of our patient relationships to CMS using PRCs. While reporting is currently voluntary, APMA suggests that its members
start using these modifiers now in order to provide CMS with

this information and to be prepared for mandatory reporting
when it starts.
n
For further advice, contact the Health Policy and
Practice department at healthpolicy.hpp@apma.org.

References:
MLN Matters Number: MM11259, Reporting the HCPCS Level II
Modifiers of the Patient Relationship Categories and Codes
MACRA Patient Relationship Categories and Codes: Frequently
Asked Questions (FAQ) CMS 2018
Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973,
1977, 1981, 1983-2018 by the AMA. All rights reserved. CPT is a registered trademark of the AMA.

Patient Relationship Category and Code (PRC)

Description of PRC

X1-Continuous/Broad Services

For reporting services by clinicians who provide the principal
care for a patient, with no planned endpoint of the relationship.
Services in this category represent comprehensive care, dealing
with the entire scope of patient problems, either directly or
in a care coordination role. Reporting clinician service examples include primary care services and specialists providing
comprehensive care to patients in addition to specialty care.

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. A
reporting clinician service example would be a rheumatologist
taking care of the patient's rheumatoid arthritis longitudinally
but not providing general primary care services.

X3-Episodic/Broad Services

For reporting services by clinicians who have broad responsibility for the comprehensive needs of the patient, that is limited
to a deﬁned period and circumstance, such as a hospitalization.
A reporting clinician service example would include a hospitalist
providing comprehensive and general care to a patient while the
patient is admitted to the hospital.

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. A reporting clinician service example would be an orthopedic surgeon performing a knee replacement and seeing the patient
through the postoperative period.

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.
A reporting clinician service example would be a radiologist's
interpretation of an imaging study ordered by another clinician.

APMA News July/August 2019

APMA News - July/August 2019

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