(Medicare Claims Processing Manual)

D.  Providers and Practitioners Affected.   The functional reporting requirements apply to the therapy services furnished by the following providers:  hospitals, CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (when the beneficiary is not under a home health plan of care).  It applies to the following practitioners: physical therapists, occupational therapists, and speech- language pathologists in private practice (TPPs), physicians, and NPPs as noted above.  The term clinician is applied to these practitioners throughout this manual section.  (See definition section of Pub. 100- 02, Chapter 15, section 220.)   E.  Function -related G -codes   There are 42 functional G -codes, 14 sets of three codes each.  Six of the G -code sets are generally for PT and O T functional limitations and eight sets of G -codes are for SLP functional limitations.   The following G -codes are for functional limitations typically seen in beneficiaries receiving PT or OT services.  The first four of these sets describe categories of f unctional limitations and the final two sets describe other functional limitations, which are to be used for functional limitations not described by one of the four categories.   NONPAYABLE G -CODES FOR FUNCTIONAL LIMITATIONS   Code  Long Descriptor  Short Descriptor  Mobility G -code Set  G8978  Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals  Mobility current status  G8979  Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting  Mobility goal status  G8980  Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end report ing Mobility D/C status  Changing & Maintaining Body Position G -code Set  G8981  Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals  Body pos current status    G8982  Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting  Body pos goal status  G8983  Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting  Body pos D/C status  Carrying, Moving & Handling Objects G -code Set  G8984  Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals  Carry current status  G8985  Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting  Carry goal status  G8986  Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting  Carry D/C status  Self Care G -code Set  G8987  Self care  functional limitation, current status, at therapy episode outset and at reporting intervals  Self care current status  G8988  Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to e nd reporting  Self care goal status  G8989  Self care functional limitation, discharge status, at discharge from therapy or to end reporting  Self care D/C status   The following other PT/OT functional G -codes are used to report:    a beneficiarys functional  limitation that is not defined by one of the above four categories;    a beneficiary whose therapy services are not intended to treat a functional limitation;    or a beneficiarys functional limitation when an overall, composite or other score from a functio nal assessment too is used and it does not clearly represent a functional limitation defined by one of the above four code sets.   Code  Long Descriptor  Short Descriptor  Other PT/OT Primary G -code Set  G8990  Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals  Other PT/OT current status    Code  Long Descriptor  Short Descriptor  G8991  Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporti ng intervals, and at discharge or to end reporting  Other PT/OT goal status  G8992  Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting  Other PT/OT D/C status  Other PT/OT Subs equent G -code Set  G8993  Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals  Sub PT/OT current status  G8994  Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting  Sub PT/OT goal status  G8995  Other physical or occupational subsequent functional limitation, discharge from therapy or end reporting.  Sub PT/OT D/C status   The following G -codes are for functional limitations typically seen in beneficiaries receiving SLP services.  Seven are for specific functional communication measures, which are modeled after the National Outcomes Measurement System (NOMS), and one is for any other measure not described by one of the other seven.   Code  Long Descriptor  Short Descriptor  Swallowing G -code Set  G8996  Swallowing functional limitation, current status, at therapy episode outset and at reporting intervals   Swallow current status  G8997  Swallowing functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting   Swallow goal status  G8998  Swallowing functional limitation, discharge status, at discharge from therapy or to end reporting  Swallow D/C status  Motor Speech G -code Set  (Note: These codes are not sequentially numbered)  G8999  Motor speech functional limitation, current status, at therapy episode outset and at reporting intervals  Motor speech current status  G9186  Motor speech functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting  Motor speech goal status    Code  Long Descriptor  Short Descriptor  G9158  Motor speech functional limitation, discharge status, at discharge from therapy or to end reporting  Motor speech D/C status  Spoken Language Comprehension G -code Set  G9159  Spoken language comprehension functional limitation, current status, at therapy episode outset and at reporting intervals  Lang comp current status  G9160  Spoken language comprehension functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting   Lang comp  goal status  G9161  Spoken language comprehension functional limitation, discharge status, at discharge from therapy or to end reporting  Lang comp D/C status  Spoken Language Expressive G -code Set  G9162  Spoken language expression functional limitation, current status, at therapy episode outset and at reporting intervals  Lang express current status  G9163  Spoken language expression functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting   Lang press goal status  G9164  Spoken language expression functional limitation, discharge status, at discharge from therapy or to end reporting  Lang express D/C status  Attention G -code Set  G9165  Attention functional limitation, current status, at therapy episode outset and at reporting intervals  Atten current status  G9166  Attention functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discha rge or to end reporting  Atten goal status  G9167  Attention functional limitation, discharge status, at discharge from therapy or to end reporting   Atten D/C status  Memory G -code Set  G9168  Memory functional limitation, current status, at therapy episode outset and at reporting intervals   Memory current status  G9169  Memory functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting   Memory goal status  G9170  Memory functional limitation, discharge status, at discharge from therapy or to end reporting   Memory D/C status  Voice G -code Set  G9171  Voice functional limitation, current status, at therapy episode outset and at reporting intervals   Voice current status    Code  Long Descriptor  Short Descriptor  G9172  Voice functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting   Voice goal status  G9173  Voice functional limitation, discharge status, at discharge from therapy or to end reporting  Voice D/C status   The following other SLP G -code set is used to report:    on one of the other eight NOMS -defined functional measures not described by the above code sets; or    to report an overall, composite or other score from assessment tool that does not clearly represent one of the above seven categorical SLP functional measures.   Code  Long Descriptor  Short Descriptor  Other Speech Language Pathology G -code Set  G9174  Other speech language pathology functional limitation, current status, at therapy episode outset and at reporting intervals  Speech lang current status  G9175  Other speech language pathology functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting   Speech lang goal status  G9176  Other speech language pathology functional limitation, discharge status, at discharge from therapy or to end reporting  Speech lang D/C status   F.  Severity/Complexity Modifiers   For each nonpayable functional G -code, one of the modifiers listed below must be used to report the severity/complexity for that functional limitation.   Modifier  Impairment Limitation Restriction  CH 0 percent impaired, limited or restricted  CI At least 1 percent but less than 20 percent impaired, limited or restricted  CJ At least 20 percent but less than 40 percent impaired, limited or restricted  CK At least 40 percent but less than 60 percent impaired, limited or res tricted  CL At least 60 percent but less than 80 percent impaired, limited or restricted  CM At least 80 percent but less than 100 percent impaired, limited or restricted  CN 100 percent impaired, limited or restricted   The severity modifiers reflect the beneficiarys percentage of functional impairment as determined by the clinician furnishing the therapy services.   G.  Required Reporting of Functional G -codes and Severity Modifiers     The functional G -codes and severity modifiers listed above are used in t he required reporting on therapy claims at certain specified points during therapy episodes of care.   Claims containing these functional G -codes must also contain another billable and separately payable (non -bundled) service.  Only one functional limitati on shall be reported at a given time for each related therapy plan of care (POC).   Functional reporting using the G -codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims:    At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service);    At least once every 10 treatment days, which corresponds with the progress reporting period;    When  an evaluative procedure, including a re -evaluative one, ( HCPCS/CPT codes  92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97161, 97162 ,97163, 97164, 97165, 97166, 97167, 97168) is furnished and billed;    At the time of discharge from th e therapy episode of care(i.e., on the date services related to the discharge [progress] report are furnished); and    At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is necessary.    At the time reporting is begun for a new or different functional limitation within the same episode of care (i.e., after the reporting of the prior functional limitation is ended)   Functional reporting is required on claims throughout the entire episode of care.  When the beneficiary has reached his or her goal or progress has been maximized on the initially selected functional limitation, but the need for treatment continues, reporting is required for a second functional limitation using another set of G -codes.  I n these situations two or more functional limitations will be reported for a beneficiary during the therapy episode of care.  Thus, reporting on more than one functional limitation may be required for some beneficiaries but not simultaneously.   When the be neficiary stops coming to therapy prior to discharge, the clinician should report the functional information on the last claim.  If the clinician is unaware that the beneficiary is not returning for therapy until after the last claim is submitted, the clin ician cannot report the discharge status.   When functional reporting is required on a claim for therapy services, two G -codes will generally be required.     Two exceptions exist: