Ready! Set! Report! Patient Relationship Modifiers

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The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) required the Centers for Medicare & Medicaid Services (CMS) to develop Patient Relationship Categories and Codes (PRC) to help attribute patients and episodes to one or more physicians/applicable clinicians for purposes of implementing the Quality Payment Program cost measurement. The PRC are intended to define the relationship and responsibility of physicians/clinicians with patients at the time of furnishing a service and/or procedure and then to facilitate the attribution of patients and episodes to one or more physicians/clinicians, and to allow clinicians to self-identify their patient relationships. 

To accomplish this important assignment, the CMS solicited extensive input from physicians/clinicians and other stakeholders at every step of the development process:

• April 2016: Draft PRC Modifier list released for public comment
• December 2016: Modified PRC Modifier list released for public comment
• May 2017: Operational PRC Modifier list released for public comment
• November 2017: Current operational PRC Modifier list published in the CY 2018 Medicare Physician Fee Schedule Final Rules (See Table 1 for the PRC Modifiers and Descriptions) 
• Currently: PRC Modifiers are in a voluntary reporting period

The CMS has multiple goals for the voluntary reporting period: 

• To educate physicians/clinicians and stakeholders about proper coding of patient relationships;
• To give physicians/clinicians an opportunity to gain familiarity with the patient relationship categories and experience submitting the PRC Modifiers; and
• To collect data for validity and reliability testing of the PRC Modifiers before their potential use in the cost measure attribution methodology for the Quality Payment Program. 

Medicare Part B Merit-based Incentive Payment System (MIPS) eligible clinicians may now voluntarily report their patient relationships on Medicare claims for items and services furnished by using the Level II HCPCS PRC Modifiers. However, all eligible clinicians (MIPS and non-MIPS) can report their patient relationships on their Medicare claims. In the future, use of PRC Modifiers will be mandatory and will be tied to the MIPS cost measures. To ease the transition, the CMS advises eligible clinicians to take this opportunity to incorporate the PRC Modifiers into every Medicare claim line. 

NOTE: During this voluntary period, whether and how the modifiers are reported on claims will not affect Medicare reimbursement and will have no impact on Medicare beneficiaries. 

The CMS have been working hard to engage stakeholders in the PRC Modifier use through education and outreach, such as webinars, listening sessions, focus groups, and targeted outreach to specialties and practice management organizations. This author participated in several of these programs and found them to be very informative. Following are some pointers that were shared at the CMS educational programs:

On May 10, 2019, the CMS released Change Request 11259 (https://tinyurl.com/y6tsh9a6) and a Medicare Learning Network MLN Matters article number MM11259 (https://tinyurl.com/y2keu2mf) that discusses reporting the PRC Modifiers. In addition, the MACRA Feedback page on the CMS Web Site (https://tinyurl.com/y2wz7446) contains PRC Modifier educational materials as well as excellent scenarios along with the appropriate PRC Modifiers for each scenario. Finally, slides, audio-recordings, and transcripts about PRC Modifiers are available at:  https://tinyurl.com/zmqpmtt.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

• The CMS has not determined the duration of the voluntary reporting period. In fact, the CMS may adjust the length of the voluntary period based on the physician/clinician adoption of the PRC Modifiers, data analysis findings, stakeholder feedback, and so forth. The mandatory PRC Modifier reporting must be established through rulemaking, which will make everyone aware of the mandatory reporting date. 
• An easy way to think of the Patient Relationship Categories is:
  • “Continuous” and “Episodic” refer to the length of the clinician-patient interaction, but they are not defined by a specific number of days
  • “Broad” and “Focused” refer to the focus of the clinical care that is provided in that interaction
• The Patient Relationship Categories allow physicians/clinicians to show specific patient relationships, but they are dynamic and flexible. The physician/clinician can self-report a different PRC Modifier for each service/procedure on a claim and/or on different claims as the patient’s needs change. For example: a physician/clinician can have an episodic/focused relationship with the patient at first, which can later become a continuous/focused relationship. 
• All physicians/clinicians who are members of the care team involved in a patient’s care should self-identify their own relationship with the patient.
• Focused patient relationships have a discrete time window, but they can vary from one physician/clinician to another.
• Even if the physician/clinician has the same patient relationship for each encounter, the PRC Modifier should be included on each claim line item and on each claim. 
• Physicians/clinicians should establish a process for self-reporting the appropriate PRC Modifier for each service/procedure reported on the Medicare claim. Some may do their own coding and the PR Modifier can be easily appended. Others may have coders who determine correct codes and modifiers. In that case, the physicians/clinicians should include the patient relationship in their documentation so the coder will know which PRC Modifier to report. Finally, physicians/clinicians should be sure that their electronic health record, super bills, and coding/billing software are set-up to accept the new PRC Modifiers.
• The CMS has instructed the Medicare Administrative Contractors to process claims that report the new PRC Modifiers. 
• Facilities such as diagnostic laboratories should not report PRC Modifiers because the modifiers are only appropriate for reporting physician/clinician services on Medicare claims.