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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:

  • Skilled Nursing Facilities (for beneficiaries in a Part B stay)
  • Rehabilitation Agencies
  • Home Health Agencies (for beneficiaries who are not under a Home Health plan of care, are not homebound, and whose therapy or other services are not paid under the Home Health prospective payment system)
  • Comprehensive Outpatient Rehab Facilities (CORFs) for PT, OT, and SLP services
  • Hospitals, including beneficiaries in Outpatient and Emergency Departments, and inpatients paid under Part B
  • Critical Access Hospitals
  • Therapists in Private Practice: Physical Therapists (PTs), Occupational Therapists (OTs), and Speech Language Pathologists (SLPs)

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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:

  • At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;
  • At least once every 10 treatment days on the claim for services on the same DOS that the services related to the progress report are furnished;
  • At the DOS that an evaluative or re-evaluative procedure code is submitted on the claim; and
  • At the time of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., this may occur when the beneficiary discontinues therapy unexpectedly.

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:

  • another separately payable (non-bundled) service;
  • functional severity modifier in the range CH – CN;
  • therapy modifier indicating the discipline of the plan of care (POC) – GP, GO or GN – for PT, OT, and SLP services, respectively;
  • date of the corresponding payable service;
  • nominal charge, e.g., a penny;
  • completion of the units field with “1” unit of service; and
  • all other currently required claims data elements as described in the claims processing manuals.

Turbo PT Helps Therapist Comply

Turbo PT helps therapists comply with Functional Reporting by:

  • Including G-code specifications and impairment modifiers in the Turbo PT EMR.
  • Automatically alerting you every 1st and 10th visit for Function Reporting and reevaluations.
  • Streamlining G-code and impairment modifier entry based on your workflow both through charge entry and documentation.

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