G-Codes and Functional Outcomes

Questions About 2013: G-Codes and Functional Outcomes


Why?
CMS was mandated to collect information regarding patient's function and condition, therapy services received, and outcomes achieved on patient function on the claim forms starting in 2013.The categories selected by CMS are from the International Classification of Functioning, Disability and Health (ICF). In the ICF, "functional limitation" generally encompasses both the terms "activity limitations" and "participation restrictions" and changes achieved within these were best representative of therapy services. CMS intends to utilize this information in the future to reform payment for outpatient therapy services

How?
To track patient progress throughout the episode of care, nonpayable G-codes and modifiers would be included on the claim forms to capture data on the patient's functional limitations (a) at the outset of the therapy episode (Evaluation and Reevaluation); (b) at specified points during treatment (every 10th visit) ; and (c) at discharge. In addition, the therapist's projected goal for functional status at the end of treatment would be reported on the first claim for services and periodically throughout the episode. To indicate the extent of the severity of the functional limitation the therapist would choose from a set of seven modifier codes. Therapists must use a valid and reliable objective measure and/or assessment tool to quantify functional limitations.

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When?
The reporting of the functional limitations on the claim form will be implemented on January 1, 2013. Please note that CMS sets forth a testing period from January 1, 2013, until July 1, 2013. After July 1, 2013, claims submitted without the appropriate G-codes and modifiers would be returned unpaid.

Who?
All practice settings that provide outpatient therapy services billing under Medicare Part B must include this information on the claim form. This applies to physical therapy, occupational therapy, and speech therapy services furnished in hospitals, Critical Access Hospitals (CAH's), Skilled Nursing Facilities (SNF's), Comprehensive Outpatient Rehabilitation Facilities (CORFs), rehabilitation agencies, home health agencies (when the patient is not under a home health plan of care), and in private offices of therapists, and nonphysician practitioners.

What?
The G-Codes for Claims-Based Functional Reporting would address the following Functional Limitations (SLP codes not listed here):

  • Mobility: Walking & Moving Around
  • Changing & Maintaining Body Position
  • Carrying, Moving & Handling Objects
  • Self Care
  • Other PT/OT Primary Functional Limitation
  • Other PT/ OT Subsequent Functional Limitation

Where?
Therapists will need to document in the medical record how they made the modifier selection as well as record their objective measure and choice of tool. For each nonpayable G-code on the claim, the line of service would also need one of the severity modifiers, the corresponding GO, GP, or GN therapy modifier to indicate the respective therapy discipline and related plan of care; and the date of service it references.

Moving Forward

Therapists will need to document in the medical record how they made the modifier selection as well as record their objective measure and choice of tool. For each nonpayable G-code on the claim, the line of service would also need one of the severity modifiers, the corresponding GO, GP, or GN therapy modifier to indicate the respective therapy discipline and related plan of care; and the date of service it references.