-X modifiers: They’re not just for unbundling

March 29th, 2019 / By Rebecca Caux-Harry

For several years now we’ve had four -X modifiers, generally presented as -X (E, P, S, U) which can be used instead of the -59 modifier to unbundle procedure codes when appropriate. In the 2018 Final Rule, we were given five more -X modifiers, specifically -X1 through -X5. These are the Patient Relationship Codes required by MACRA. CMS decided to create the new -X procedure modifiers to append to procedure codes rather than create new procedure codes to report the relationships. Reporting is currently voluntary and the reporting period began January 1, 2018.

The Patient Relationship Codes and their respective categories are:

X1-Continuous/Broad Services

This would describe visits with your primary care provider with no expected end date.

X2-Continuous/Focused Services

This would describe ongoing visits with a specialist for management of chronic conditions.

X3-Episodic/Broad Services

This would describe visits with a provider for a specific period of time, for general services, for example a hospitalist during an inpatient stay.

X4-Episodic/Focused Services

This would describe visits with a provider for a specific period of time, for a specific issue, for example a surgeon during an inpatient stay.

X5-Only as ordered by another clinician

This would describe services like testing.

We are to report the relationship code for each line-item of the claim and the relationship may differ for each line-item. These codes do not impact reimbursement; therefore, many providers and/or coders may elect to not report until mandatory. The purpose of the codes is to allow CMS to attribute healthcare costs when a patient is being treated by more than one provider. 

The voluntary reporting period allows for questions to arise as physicians or coders attempt to implement this rule and find gaps in direction. For example, is there a documentation requirement for using these codes? How do we select the appropriate code in an incident-to or shared visit scenario? Will commercial payers follow suit? If not, we now must consider the payer when deciding to add these codes to a claim. What about an internal medicine specialist that the patient uses as a primary care provider? If these codes become mandated, will we receive denials when the codes are missing?

Since the majority of services reported to CMS are E&M services, which are primarily coded by providers, will providers tolerate one more administrative task unrelated to patient care or reimbursement? This is the era of patients over paperwork at CMS. This additional task has no direct positive impact on patient care or experience. I, for one, hope that we find another way to track and attribute patient care costs other than adding to the overly cumbersome current coding process.

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.