Functional Limitation Reporting Overview
Beginning July 31, 2013, Functional Reporting requires physical therapist (PT), occupational therapists (OT), and speech-language pathologists (SLP) practitioners and providers to report nonpayable G-codes and modifiers to convey information about Medicare part B patients functional status including projected goal status throughout the episode of care. The Functional Reporting system will better our understanding of beneficiary conditions, outcomes, and expenditures.
Who Does Functional Reporting Apply to?
Functional Reporting applies to all Medicare part B patients when Medicare is either a primary or secondary payer. However, Medicare does not require Functional Reporting for Medicare Advantage Plans.
What providers are required to include functional reporting on their claims?
In order to receive reimbursement for outpatient therapy, Functional reporting is required for all physical therapists, occupational therapists, and speech-language pathologists billing under Medicare part B in the following settings:
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Coding Requirements for Functional Reporting
Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report nonpayable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
Functional Reporting is required on therapy claims for certain dates of service (DOS) as described below:
What are G-Codes?
G-codes are used to report a beneficiary’s functional limitation being treated and note whether the report is on the beneficiary’s current status, projected goal status, or discharge status. There are 42 functional G-codes that are comprised of 14 functional code sets with three types of codes in each set. Six of the G-code sets are generally for PT and OT functional limitations and eight of G-code sets are for SLP functional limitations.
Providers and practitioners report the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment.
What are Severity Modifiers?
For each non-payable G-code reported, a modifier must be used to report the severity level for that functional limitation. The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the providers or practitioners furnishing the therapy services. Therefore, the beneficiary’s current status, projected goal status, and discharge status are reported via the appropriate severity modifiers.
G-Code Cheat Sheet
Do you need help finding the most appropriate G-code for Functional Reporting? Enter your email to download the PQRS Cheat Sheet for Individual Measures for PT and OT.
Documentation Requirements for Functional Reporting
Providers are required to document in the patient’s medical record the functional G-codes and severity modifiers that were used to report the patient’s current, projected goal, and discharge status. For the severity modifiers, providers should include a description of how the modifiers were determined. These requirements are applicable for each date of service for which the reporting is done.
What Happens if I Don’t Do Functional Reporting?
If you and your patient are eligible for Functional Reporting as outlined above and you fail to include Functional Reporting in your claims, CMS will automatically deny them and you won’t get paid for services rendered to your Medicare part B patients.
What are the Claims Requirements?
Claims containing any of these functional G-codes must also contain:
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