8/25/2014

Functional Limitation Requirements-Reporting Overview of G codes Now Required for Payment of Services

Course Objectives 



 



Demonstrate understanding of the evolution of G-codes and next steps in outcome measures for CMS. Understand when functional limitation codes need to be entered, updated, and discontinued. Identify common entry errors and how to correct them. Understand how to assist your customer in correcting rejected claims due to missing codes. Identify other payer types might require codes.

Medicare Requirements 

As of 2013, therapists are required to report new Functional Limitation G- codes for Medicare Part B patients



January 1, 2013 began the testing phase



July 1, 2013 began the required phase. Claims need to have the new Functional Limitation G-codes in order to be paid.

1

8/25/2014

WHY ARE WE DOING THIS The Middle Class Tax Relief and Job Creation Act of 2012 states that “The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claimsbased data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act. Such strategy shall be designed to provide the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes.”

Data Collection from Claim Information CMS collects claim data for beneficiaries receiving Part B Therapy services: Therapy services furnished CPT Codes, Units (Intensity), Frequency, Duration 



Functional level at onset and periodically through episode of therapy until discharge Outcomes achieved related to patient function

CMS will use this information in the future to reform payment for Part B therapy services

Data Collection Important to Know…Functional Limitation Reporting does NOT change the way we assess or treat our patients! According to CMS… The Medicare Functional Limitation data collection system is designed to collect data that is developed in the evaluation process and assessed throughout the course of treatment. It does not prescribe how or what measures therapists use to assess functional impairment or deliver services.

2

8/25/2014

Functional Limitation Reporting o CMS has provided a series of Functional Limitation categories. o Per CMS, therapists (not assistants) must select one category for each Med B patient and develop a goal for that category. o At specified intervals, therapist will record the %age of impairment and this information will be reported to CMS o FL G-codes should be entered on a date the therapist saw the patient (not on the day the note was written if after the fact) as assessment is expected in order to update the impairment status.

SLP Functional Limitation Categories The 8 categories for SLP: 7 sets are for categorical* functional limitations: Swallow  Motor Speech  Spoken Language Comprehension  Spoken Language Expression  Attention  Memory  Voice 1 set for “Other SLP” functional limitations 

*Based on National Outcomes Measurement System (NOMS)

Example of a code set Swallowing G-code Set: Swallow current status G8996, Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals Swallow goal status G8997, Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy Swallow D/C status G8998, Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation

3

8/25/2014

Reporting Functional Limitation G-codes   



ALL Traditional Medicare Part B Therapy Services From outset of the Part B services until discharge Outset -Initial Eval or when transitions from Part A to Part B Other payers that may require code entry may include Private Insurance, Managed Care, and potentially Hospice.



G-code Reporting Points G-codes with Severity Modifiers will be reported for every Medicare Part B therapy patient. Report for:  Each Initial Evaluation  Each Therapist Progress Note  Each Updated Plan of Care or Re-evaluation  Each time there’s a change in G-code functional category (chg in goal focus-UPOC)  Each Discharge Summary

Structure of the G-codes Each functional G-code set contains:   

Current status Projected goal status Discharge status

At every reporting point 2 codes will be recorded*: Current status AND Projected goal status At discharge 3 codes will be recorded: Current, Goal, AND Discharge *Exception to this is the one time therapy visit in which all 3 codes in the set will be reported

4

8/25/2014

SLP Functional Limitation G-codes Swallow G8996 Swallow, current status, at outset and at reporting intervals G8997 Swallow, goal status, at outset, reporting intervals, discharge G8998 Swallow, discharge status, at discharge Motor Speech G8999 Motor Speech, current status, at outset and at reporting intervals G9186 Motor Speech, goal status, at outset, reporting intervals, discharge G9158 Motor Speech, discharge status, at discharge Spoken Language Comprehension G9159 Lang Comp, current status, at outset and at reporting intervals G9160 Lang Comp, goal status, at outset, reporting intervals, discharge G9161 Lang Comp, discharge status, at discharge Spoken Language Expression

G9162 G9163 G9164

Lang Express, current status, at outset and at reporting intervals Lang Express, goal status, at outset, reporting intervals, discharge Lang Express, discharge status, at discharge

SLP Functional Limitation Gcodes Attention

G9165 G9166 G9167

Attention, current status, at outset and at reporting intervals Attention, goal status, at outset, reporting intervals, discharge Attention, discharge status, at discharge

Memory

G9168 G9169 G9170

Memory, current status, at outset and at reporting intervals Memory, goal status, at outset, reporting intervals, discharge Memory, discharge status, at discharge

Voice G9171 G9172 G9173

Voice, current status, at outset and at reporting intervals Voice, goals status, at outset, reporting intervals, discharge Voice, discharge status, at discharge

Other G9174 G9175 G9176

(Auditory Discrimination, Reading Comprehension, Written Expression) Speech Lang., current status, at outset and at reporting intervals Speech Lang., goals status, at outset, reporting intervals, discharge Speech Lang., discharge status, at discharge

Selecting the G-code 

Select the code that most closely relates to the primary functional limitation being treated or reason for treatment



Must align with the Long Term Goal(s) established



The “Other SLP” functional G-code is used to report any other functional limitation not represented by one of the other 7 categorical SLP functional measures

5

8/25/2014

Selecting the G-code In cases of multiple functional limitations, the therapist determines which limitation is primary. In choosing, consider: Most clinically relevant to a successful outcome for the beneficiary; 



The one that would yield the quickest and/or greatest functional progress; or The one that is the greatest priority for the beneficiary

Severity Modifier 



For each G-code, one severity modifier must be used to report the severity for that functional measure The Severity Modifiers reflect the patient’s percentage of functional impairment as determined by the Therapist furnishing the therapy services

Severity Modifier Levels Modifier CH CI CJ CK CL CM CN

Impairment Limitation Restriction 0 percent impaired, limited or restricted At least 1 percent but less than 20 percent impaired, limited or restricted At least 20 percent but less than 40 percent impaired, limited or restricted At least 40 percent but less than 60 percent impaired, limited or restricted At least 60 percent but less than 80 percent impaired, limited or restricted At least 80 percent but less than 100 percent impaired, limited or restricted 100 percent impaired, limited or restricted

6

8/25/2014

Severity Modifier Selection 





Use the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument, as appropriate; When using multiple measurement tools during the evaluation, therapist clinical judgment is used to combine these results to determine a functional limitation percentage; Therapists can use their clinical judgment in the assignment of the appropriate modifier.

Severity Modifier Selection Where improvement is expected to be limited, the same severity modifier may be used in reporting the current and goal status Where improvement is not expected, such as for those individuals receiving maintenance therapy, the modifier used for projected goal status will be the same as the one for current status

Example of coding with modifier for swallowing Category

Severity modifier

Goal status

G8997

1‐19% impairment

Current status

G8996

Goals status

G8997

20‐39%  impairment 1‐19% impairment

Current status

G8996

1‐19% impairment

7

8/25/2014

Reporting Frequency Functional Limitation Reporting using G- codes will be required throughout the therapy episode of care 

Only one functional limitation can be reported at a given time for each therapy discipline



Though CMS recognizes that therapists treat the patient as a whole and work on more than one functional limitation at a time

Reporting G-codes There will be instances where two or more functional limitations will be reported for a single discipline, just not during the same time frame. When the reporting for the first functional limitation is complete (i.e., goal met) and the need for treatment continues, reporting is required for a second functional limitation using another set of G-codes “End One-Begin One”

“End One-Begin One” When the end of reporting on one functional limitation is completed and therapy continues within the same episode of care, the following reporting is required: -The D/C Status G-code + Severity Modifier of the ending functional limitation -The Goal Status G-code + Severity Modifier for the ending functional limitation -The Current Status G-code + Severity Modifier for the different functional limitation (using a different G- code) -The Goal Status G-code + Severity Modifier for the different functional limitation -The Current Status G-code + Severity Modifier for the different functional limitation (using a different G- code)

8

8/25/2014

Required Reporting Dates It’s Important to Know… Medicare requires that the Functional Limitation G-codes be reported on days when the patient receives a billable therapy treatment. Therefore, the Activity Date of the Progress Report or UPOC must correspond to a treatment day. While not best practice, it is OK if an assistant treated the patient on the Activity Date.

Example of coding with modifier for swallowing for interval and dc reporting Status

Category

Severity modifier

Goal status

G8997

1-19% impairment

Current status

G8996

Goals status

G8997

20-39% impairment 1-19% impairment

Current status

G8996

1-19% impairment

DC status

G8998

1-19% impairment

Documentation The Functional Limitation G-codes should be consistent with the functional limitations identified in the documentation and should align with the Long Term Goals It’s Important to Know… You will need to document the functional assessments used when first selecting the Functional Limitation category and Severity Modifier. Those same assessments must be used every time when updating the patient’s status for that same FL category (i.e., in Progress Reports, UPOCS, Discharge Summaries).

9

8/25/2014

Progress Report and UPOC Reporting For the Functional Limitation Category that is currently active: Select the appropriate Severity Modifier for the Current Status G-code Select the appropriate Severity Modifier for the projected Goal Status G-code If this is a Progress Report the Goal Status for the current Functional Limitation should remain the same as on the previous report  A progress note is required every 10 treatment days  A UPOC is required if the Goal Status for the current Functional Limitation is changing since the Goal Status should align with the LTGs(s) and likely, then, the LTG(s) is also changing. Complete if a medically necessary re-evaluation is completed due to change of status in patient. Document the specific functional assessment(s) used in determining your Severity Modifier.

Discharge Summary Reporting For the Functional Limitation Category that is currently active:

Select the appropriate Severity Modifier for the Discharge Status G-code Select the appropriate Severity Modifier for the projected Goal Status G-code. The Goal Status for the current Functional Limitation should remain the same as on the previous report Document the specific functional assessment(s) used in determining your Severity Modifier. The date of the FL g code entry must be the same as the last day of treatment (not necessarily when the dc note is written) regardless of planned or unplanned discharge For unplanned discharges, the Discharge FLR is not required.

In Summary Select a single Functional Limitation Category that most closely relates to the primary functional limitation being treated Select the appropriate Severity Modifier for the Current Status G-code Select the appropriate Severity Modifier for the projected Goal Status Gcode Document the specific functional assessment(s) used in determining your Severity Modifier (so this same assessments can be used in future reporting for this patient) and continue with this FL G code until the goal status is met, then modify with a UPOC or chose another category to focus on for the remainder of the treatment episode.

10

8/25/2014

Example 4/30/14

G9169

20‐49% impairment

4/30/14

G9168

60‐79% impairment

Mistakes are often made…   

Let’s practice identifying and correcting errors Identifying common errors to avoid Remember: 

If a Progress Report (note, UPOC) has an Activity Date on a day in which the patient was not treated, then the information used to complete the report is not based upon any patient assessment completed that day (since there is no billed treatment), but on observations and assessments completed in the previous treatment day(s). To correct, the Activity Date of the note must move back to the previous treatment date.

Example 7/25/14 7/25/14

G8997 G8996

8/11/14 8/11/14

G8997 G8996

1‐19% impairment 20‐39%  impairment 1‐19% impairment 1‐19% impairment

11

8/25/2014

Example 4/4/14 4/4/14 4/25/14 4/25/14 4/28/14 4/28/14 5/21/14 5/21/14 5/23/14 5/23/14

Swallowing G8997 Goal G8996 Current G8997 Goal G8998 DC Lang. Compreh. G9160 Goal G9159 Current G9159 Goal G9160 Current G9160 Goal G9161 DC

1‐19% impairment 20‐39% impairment 1‐19% impairment 1‐19% impairment 20‐39% impairment 60‐79% impairment 20‐39% impairment 40‐59% impairment 20‐39% impairment 40‐59% impairment

Example 7/24/14

G9169 Goal

7/24/14

G9168 Current

7/28/14 7/28/14 8/6/14 8/6/14

G9169 Goal G9168 Current G 9169 Goal G 9168 Current

CI—1 to 19%  impaired CK—40 to 50%  impaired

CK—40 to 59%  impaired

Claim rejections 

Some Medicare Administrative Contractors (MACs) have posted on their websites that they are aware of issues causing PT, OT, and SLP services to reject in error. As several of the MACs have identified a Common Working File (CWF) issue causing rejection of G-code claims, it is possible that this CWF issue is impacting all MACs.

 Verify that the claim submitted to Medicare matches the G-codes, Severity Modifiers, and dates on CPT logs. In some instances you must verify that the G-codes on the previously paid claim match what is on the billing log. G-code errors in one month can cause a subsequent month’s claim to reject.  If the G-codes on CPT logs and the current/previous claims match and appear to be accurate, then it might be a MAC processing issue. If you suspect that it might be a MAC issue check your MAC’s website or contact your MAC for directions.

12

8/25/2014

Resources Updates to the Medicare Benefit Policy Manual: Transmittal R165BP Updates to the Medicare Claims Processing Manual: Transmittal R2622CP 

MLN Matters: MM8005http://cms.gov/Outreach-andEducation/Medicare- Learning-NetworkMLN/MLNGenInfo/index.html

13