Tests and G-Codes

The time has arrived. Documenting and tracking functional limitations is now the status quo. For TherAssist users, the latest upgrades and features will put you on a path to compliance and for those considering an Electronic Medical Record, the "What are you waiting for?" moment has finally come. To review, here's how and why we got to this point:

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.

Program Tip

Need to fill an appointment at the last second? TherAssist's Waiting List is the perfect solution to rapidly assign appointments to patients that want to come in, but couldn't be accommodated because of a full schedule. This feature allows you to scroll through patient's, access their contact numbers, and even select a preferred therapist.

In order to track patient's functional limitations and progress, non-billable G-codes and modifiers are used on the claim forms to report data for the Evaluation, every 10th visit and at discharge as well as the therapist's projected goal for functional status. 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.

The following screenshots show you how TherAssist makes compliance part of your documentation process. Therapist selects Functional Outcome Tools just before the SmartBill. TherAssist calculates score and then recommends the best modifier.

As always, within NoteStation, you can easily access the patient history of scores for all tests, measures and visits. G-codes and modifiers can be reviewed in SmartBill as part of your documentation.

Moving Forward

TherAssist's Electronic Medical Record (EMR) will facilitate the processes and steps involved in reporting functional outcome measures and recording codes. An EMR will become invaluable as you are asked to provide more detail and content as part of your documentation.