Medicare Functional Outcome Reporting (G-Coding)

Beginning on January 1st, 2013 Speech Pathologists, Occupational Therapists, and Physical Therapists must begin reporting functional outcomes on their Medicare claims.  Functional outcomes are reported using what is being referred to as G-Codes.  While this took effect on January 1st, 2013, Medicare had given a transitionary period up until July 1st, 2013.  That transition period, now having ended, if you are not properly reporting your outcome measures (G-Codes), then you will not get paid. 

In a nutshell

You will be including additional codes (on the service lines of the CMS-1500) on your Medicare claims to report the beneficiaries progress towards their goals.  First, a primary functional limitation is determined for the patient (Medicare beneficiary).  Then, progress is reported on your Medicare claims using two additional codes (G-Codes) on your claim forms.  These two additional codes are used to indicate the Goal Status and the Current Status towards that goal.  The status is reported using a severity modifier (i.e. CK modifier refers to At least 40 percent but less than 60 percent impaired, limited or restricted).  These G-Codes must be reported on the initial visit, every 10th visit (corresponding to the new progress reporting requirements), on discharge, and whenever the primary functional limitation (defined below) changes.

Recorded Webinar

Therabill will be hosting webinars over the next several months on Medicare and Functional Limitation Reporting.  We recorded our first webinar and posted it to the link above.  For convenience, a link to the recording is listed at the bottom of this page.

How this Article is Laid Out

This article is going to give an overview of the functional outcome reporting laid out in the 2013 Medicare Physicians Fee Schedule.  We will go over the following topics in the following order.

1. Primary Functional Limitation: What is it and how do you determine the primary functional limitation.
2. The G-Code severity and complexity modifiers: What are they and what does each modifier mean.
3. Reporting Requirements: What needs to be reported and how often.
4. G-Coding in Therabill: How does Therabill collect the G-Coding information.
5. Example: A simple example of reporting throughout a therapy episode.

Primary Functional Limitation

Therapists (SLP, PT, and OT) are required to report on the primary functional limitation.  If the Medicare beneficiary has more than one functional limitation, then the healthcare provider must  make a determination as to which functional limitation is the primary functional limitation.  The therapist may choose the functional limitation that is:

• Most clinically relevant to a successful outcome for the beneficiary;
• The one that would yield the quickest and/or greatest functional progress (e.g. select mobility over self-care even though both are addressed simultaneously and therapists expects beneficiary will attain self care goals before mobility goals); or
• The one that is the greatest priority for the beneficiary.

The G-Code Severity and Complexity Modifiers

A severity modifier is used to reflect the patient's percentage of functional impairment as determined by the therapist, physician, or NPP furnishing the therapy service.  The modifiers are defined as:

• CH - 0 percent impaired, limited or restricted
• CI - At least 1 percent but less than 20 percent impaired, limited or restricted.
• CJ - At least 20 percent but less than 40 percent impaired, limited or restricted.
• CK - At least 40 percent but less than 60 percent impaired, limited or restricted.
• CL - At least 60 percent but less than 80 percent impaired, limited or restricted.
• CM - At least 80 percent but less than 100 percent impaired, limited or restricted.
• CN - 100 percent impaired, limited or restricted.

These severity modifiers are reported with the G-Code representing the primary functional limitation.  

Deciding what modifier to use...

• Use a severity modifier that reflects the score from a functional assessment tool or other performance measurement instruments, as appropriate.
• If multiple measurement tools are used during the evaluative process, clinical judgement should be used to combine the results to determine a functional limitation percentage.
• Therapists can use their clinical judgement in the assignment of of the appropriate severity modifier.  Therapists will need to document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.
• Use the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat a functional limitation.
• In some cases, for patients where improvement is expected to be limited, the same severity measure may be used in reporting the current and goal status.

Reporting Requirements

What is reported on your claims

Each functional reporting on your claim form will require the following information (in addition to the G-Code that represents the functional impairment).

• The functional severity modifier
• The therapy modifier representing the related discipline (GP = Physical Therapy, GO = Occupational Therapy, GN = Speech and Language Pathologist)
• The date of the related therapy service
• A nominal charge.  In Therabill, the charge amount will be reported as 1 cent.
• A billable and separately payable service (in other words,  the actual therapy service you are billing for).

Reporting Frequency

The functional reporting period matches the progress reporting period.  According to the 2013 Medicare Physicians Fee Schedule, the progress reporting period has been changed from the lesser of every 10th visit or 30 days to every 10th visit.

1. Outset - The functional reporting (G-Codes and modifiers) must be reported on the claim for the date of service when the therapist furnishes the evaluation and develops the required plan of care (POC) for the beneficiary.  On the outset, the therapist will use the G-codes and modifiers to report the current status and the projected goal.  
2. Every 10th visit - The functional reporting (G-Codes and modifiers) must be reported on the claim for every 10th visit.  The therapist will report G-Codes for current status and projected goal and their corresponding severity modifiers.
3. Discharge - The functional reporting (G-Codes and modifiers) must be reported on the claim for the discharge date of service, except in cases where therapy services are discontinued by the beneficiary prior to the planned discharge visit.  On discharge, the therapist will use the G-codes for discharge status and projected goal status.
4. Change of primary functional limitation - The functional reporting (G-Codes and modifiers) must be reported on the claim when the primary functional limitation is changed.  This reporting is performed in the same way as the discharge.
5. Significant change in condition - The functional reporting (G-Codes and modifiers) must be reported when a re-evaluation is performed that results in an alteration of the goals in the beneficiaries plan of care.

G-Coding in Therabill

The G-Coding in Therabill will be pretty seamless.  You will simply define the primary functional limitation of the patient on the add / edit client form.  Any updates to the primary functional limitation will also be documented for you (you should have a re-evaluation documented).  In addition to indicating the primary functional limitation, you will also supply a projected goal (a percent impairment) on the add/edit client form.  Any updates to the projected goal will also be recorded by Therabill (you should have a re-evaluation documented).

A current status input will be available to you on all add / edit session forms in Therabill.  You should enter the current status (a percentage) on every session, however, it is only required on every 10th visit.  Therabill will track the visit number and report the proper G-Code and Modifier based on the information you have supplied for the primary functional impairment (on add/edit client form), the projected goal (on add/edit client form), and the status updates (on the add/edit session form).

Example

You intake a new patient and you document that their primary functional limitation is Swallowing (which is one of the 14 functional limitation categories defined in the 2013 Medicare Physicians Fee Schedule).  You determine that their current status is 85 percent impaired and you set a goal of 25 percent impaired. 

Your claim for the initial visit will have the following G-Codes listed in the services lines.

• G-Code G8996 (current status) with modifier GP (for SLP) and modifier CM (form 80% to 99%)
• G-Code G8997 (projected goal) with modifier GP (for SLP) and modifier CJ (for 20% to 39%)

On the tenth visit you determine that their current status is 57% impaired and the following G-Codes will be listed on your Medicare claim.

• G-Code G8996 (current status) with modifier GP (for SLP) and modifier CK (for 40% to 59%)
• G-Code G8997 (projected goal) with modifier GP (for SLP) and modifier CJ (for 20% to 39%)

Every 10th visit you will report as above.  If the Goal is ever updated (i.e. from a re-evaluation) the new goal and current status will need to be reported on the claim form for that re-evaluation.

On discharge, you determine that their current level of impairment is 33% and the following G-Codes will be listed on your Medicare claim.

• G-Code G8998 (discharge status) with modifier GP (for SLP) and modifier CJ (for 20% to 39%)
• G-Code G8997 (projected goal) with modifier GP (for SLP) and modifier CJ (for 20% to 39%)

Recorded Webinar

Medicare and Functional Limitation Reporting.