CMS: What you need to know about new modifiers X1, X2, X3, X4, X5

May 20, 2019 / By Barbara Aubry, RN

Oh great—more new modifiers!

If you’re like me, I read my CMS updates and focus on what needs to be managed based on regulatory deadlines. Back in 2016, I read about the projected use of new modifiers for “Patient Relationship Categories and Codes (PRC)” and thought I would deal with them when necessary. Well, the day has arrived; see CR 11259, Transmittal R2300OTN, effective 1/1/2018, implementation date 8/12/2019.

Some background from CMS:

 “Section 1848(r)(3) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires the development of PRC codes to help the attribution of patients and episodes to one or more physicians or applicable practitioners (clinicians) for purposes of cost measurement. Section 1848(r)(4) of the Act requires clinicians, as determined appropriate by the Secretary, to include the applicable PRC codes on claims for items and services furnished on or after January 1, 2018. 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.

My take

According to CMS the codes are currently in a “voluntary reporting period; whether and how the codes are reported on claims will not affect reimbursement. For now, the modifiers have no impact on beneficiaries. Reporting of these modifiers will be mandatory in the near future and CMS advises clinicians to participate during the voluntary reporting period to ease transition.”

Oh dear—I see some red flags immediately: What exactly will be the impact of the use of these modifiers on beneficiaries in the future? How will future reimbursement be impacted? Should coders be responsible for assigning the modifiers? Or is this the provision of the clinician since a coder should not be expected to anticipate the length of required clinical care? Will diagnoses be required to be reported in support of certain modifiers? Will dates of service be measured to determine chronicity? Are the modifiers to be appended to every E/M CPT code? Something else?

When reading the modifier descriptors, I believe they’re fairly clear except for X5 which actually represents (as an example) a radiologist reading an x-ray, MRI, CT, etc., but what happens with X3 for surgical services that result in infection or some other complication that must be followed for a longer term than generally expected by the surgeon? I realize the goal of improving quality and reducing cost, but is tracking of these modifiers going to be used to parcel out allowable services by provider type? For example, can hypertension be successfully managed by primary care or is cardiology needed? If it’s simple hypertension and the patient is compliant than the answer is likely “yes,” but does this mean beneficiaries will no longer be “allowed” so see a cardiologist for hypertension treatment absent some other type of coronary artery disease (CAD)? What exactly will CMS do with the data they gather?

I think it is very important that practices pay special attention to the use of these modifiers. Have clinicians begin assigning and reporting the modifiers STAT and be sure to carefully include the specific diagnosis for the problem treated. Be aware that CMS will be data mining—now is the time to give up the use of any non-specific ICD-10-CM codes when better options exist. CMS is sharing the importance (italics added since this is essential):

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

  1. For clinicians to gain familiarity with the categories and experience submitting the codes
  2. 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”

For more background information, visit the CMS website.

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.