(Medicare Claims Processing Manual)

 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:   1. Therapy services under more than one therapy POC --  Claims may contain more than two nonpayable functional G -codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.   2. One-Time Therapy Visit--  When a beneficiary is seen and  future therapy services are either not medically indicated or  are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G -codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.   Each reported functional G -code must also contain the following line of service information:    Functional severity modifier    Therapy modifier indicating the related discipline/POC -- GP, GO or GN -- for PT, OT, and SLP services, respectively    Date of the related therapy service    Nominal charge, e.g., a penny, for institutional claims submitted to the A/B MACs (A).   For professional claims, a zero charge is acceptable for the service line.  If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included.   NOTE : The KX modifier is not required on the claim line for nonpayable G -codes, but would be required with the procedure code for medically necessary therapy services furnished once the beneficiarys annual cap has been reached.   The following example demonstrates how the G -codes and modifiers are used.  In this example, the clinician determines that the beneficiarys mobility restriction is the most clinically relevant functional limitation and selects the Mobility G -code set (G8978  G8980) to represent the beneficiarys functional limitation.  The clinician also determines the severity/complexity of the beneficiarys functional limitation a nd selects the appropriate modifier.  In this example, the clinician determines that the beneficiary has a 75 percent mobility restriction for which the CL modifier is applicable.  The clinician expects that at the end of therapy the beneficiaries will hav e only a 15 percent mobility restriction for which the CI modifier is applicable.  When the beneficiary attains the mobility goal, therapy continues to be medically necessary to address a functional limitation for which there is no categorical G -code. The clinician reports this using (G8990  G8992).     At the outset of therapy --  On the DOS for which the initial evaluative procedure is furnished or the initial treatment day of a therapy POC, the claim for the service will also include two G -codes  as shown below.    G8978- CL to report the functional limitation (Mobility with current mobility limitation of at least 60 percent but less than 80 percent impaired, limited or restricted)    G8979- CI to report the projected goal for a mobility restriction of at least 1 percent but less than 20 percent impaired, limited or restricted.   At the end of each progress reporting period--   On the claim for the DOS when the services related to the p rogress report (which must be done at least once each 10 treatment days) are furnished, the clinician will report the same two G -codes but the modifier for the current status may be different.    G8978 with the appropriate modifier are reported to show the beneficiarys current status as of this DOS.  So if the beneficiary has made no progress, this claim will include G8978 -CL.  If the beneficiary made progress and now has a mobility restriction of 65 percent CL would still be the appropriate modifier for 65 percent, and G8978- CL would be reported in this case.  If the beneficiary now has a mobility restriction of 45 percent, G8978- CK would be reported.    G8979- CI would be reported to show the projected goal.  This severity modifier would not change unless the clinician adjusts the beneficiarys goal.   This step is repeated as necessary and clinically appropriate, adjusting the current status modifier used as the beneficiary progresses through therapy.   At the time the beneficiary is discharged from the therapy  episode.   The final claim for therapy episode will include two G -codes.    G8979- CI would be reported to show the projected goal.  G8980 -CI would be reported if the beneficiary attained the 15 percent mobility goal.   Alternatively, if the beneficiarys mob ility restriction only reached 25 percent; G8980 -CJ would be reported.   To end reporting of one functional limitation--  As noted above, functional reporting is required to continue throughout the entire episode of care.  Accordingly, when further therapy is medically necessary after the beneficiary attains the goal for the first reported functional limitation, the clinician would end reporting of the first functional limitation by using the same G -codes and modifiers that would be used at the time of discharge. Using the mobility example, to end reporting of the mobility functional limitation, G8979- CI and G8980- CI would be reported on the same DOS that coincides with end of that progress reporting period.    To begin reporting of a second functional limitation . At the time reporting is begun for a new and different functional limitation, within the same episode of care (i.e., after the reporting of the prior functional limitation is ended).  Reporting on the second functional limitation, however, is n ot begun until the DOS of the next treatment day --  which is day one of the new progress reporting period.  When the next functional limitation to be reported is NOT defined by one of the other three PT/OT categorical codes, the G -code set (G8990 -  G8992) for the other PT/OT primary functional limitation is used, rather than the G -code set for the other PT/OT subsequent because it is the first reported other PT/OT functional limitation.  This reporting begins on the DOS of the first treatment day following the mobility discharge reporting, which is counted as the initial service for the other PT/OT primary functional limitation and the first treatment day of the new progress reporting period.  In this case, G8990 and G8991, along with the corresponding modifiers, are reported on the claim for therapy services.   The table below illustrates when reporting is required using this example and what G -codes would be used.   Example of Required Reporting  Key:  Reporting Period (RP)  Begin RP #1 for Mobility at Episode Outset  End RP#1for Mobility at Progress Report  Mobility RP #2 Begins  Next Treatment Day  End RP #2 for Mobility at Progress Report  Mobility RP #3 Begins Next Treatment Day  D/C or End Reporting for Mobility  Begin RP #1 for Other PT/OT Primary  Mobility: Walking & Moving Around                G8978  Current Status  X X  X    G 8979  Goal Status  X X  X  X  G8980  Discharge Status       X  Other PT/OT Primary         G8990  Current Status        X G8991   Goal Status        X G8992  Discharge Status         No Functional Reporting Required    X  X    H.  Required Tracking and Documentation of Functional G -codes and Severity Modifiers   The clinician who furnishes the services must not only report the functional information on the therapy claim, but, he/she must track and document the G -codes and severity modifiers used for this reporting in the beneficiarys medical record of therapy services.    For details related to the documentation requirements, refer to, Medicare Benefit Policy  Manual, Pub. 100- 02, Chapter 15, section 220.4 -  Functional Reporting.  For coverage rules related to MCTRJCA and therapy goals, refer to Pub. 100- 02:  a) for outpatient therapy services, see Chapter 15, section 220.1.2 B and b) for instructions specific to PT, OT, and SLP services in the CORF, see Chapter 12, section 10.  10.7 - Multiple Procedure Payment Reductions for Outpatient Rehabilitation Services (Rev. 3475, Issued: 03- 04-16, Effective: 06- 06-16, Implementation: 06- 06-16)  Medicare applies a multiple procedure payment reduction (MPPR) to the practice expense (PE) payment of select therapy services.  The reduction applies to the HCPCS codes contained on the list of always therapy services (see section 20), excluding A/B MAC (B) -priced, bundle d and add- on codes, regardless of the type of provider or supplier that furnishes the services.  Medicare applies an MPPR to the PE payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to mult iple units as well as multiple procedures.  Many therapy services are time- based codes, i.e., multiple units may be billed for a single procedure.  The MPPR applies to all therapy services furnished to a patient on the same day, regardless of whether the s ervices are provided in one therapy discipline or multiple disciplines, for example, physical therapy, occupational therapy, or speech -language pathology.   Full payment is made for the unit or procedure with the highest PE payment.  For subsequent units and procedures with dates of service prior to April 1, 2013, furnished to the same patient on the same day, full payment is made for work and malpractice and 80 percent payment is made for the PE for services submitted on professional claims (any claim submitted using the ASC X12 837 professional claim format or the CMS -1500 paper claim form) and 75 percent payment is made for the PE for services submitted on institutional claims (ASC X12 837 institutional claim format or Form CMS -1450).   For subsequent units  and procedures with dates of service on or after April 1, 2013, furnished to the same patient on the same day, full payment is made for work and malpractice and 50 percent payment is made for the PE for services submitted on either professional or institutional claims.   To determine which services will receive the MPPR, contractors shall rank services according to the applicable PE relative value units (RVU) and price the service with the highest PE RVU at 100% and apply the appropriate MPPR to the remaini ng services. When the highest PE RVU applies to more than one of the identified services, contractors shall additionally sort and rank these services according to highest total fee schedule amount, and price the service with the highest total fee schedule amount at 100% and apply the appropriate MPPR to the remaining services.     The therapy payment amount that has been reduced by the MPPR is applied toward the therapy caps described in section 10.2.  As a result, the MPPR may increase the amount of medically  necessary therapy services a beneficiary may receive before exceeding the caps.  The reduced amount is also used to calculate the beneficiarys coinsurance and deductible amounts.  The contractor shall use the following remittance advice messages and asso ciated codes when adjusting payment under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: CO  CARC: 59  RARC: N/A  MSN: 30.1  20 - HCPCS Coding Requirement  (Rev. 1850, Issued: 11- 13-09, Effective: 01- 01-10, Implementation: 01 -04-10)  A.  Uniform Coding   Section 1834(k)(5) of the Act requires that all claims for outpatient rehabilitation therapy services and all comprehensive outpatient rehabilitation facility (CORF) services be reported using a uniform coding system.  The current Healthcare Common Procedure Coding System/Current Procedural Terminology is used for the reporting of these services.  The uniform coding requirement in the Act is specific to payment for all CORF services and outpatient rehabilitation therapy services -  including physical therapy, occupational therapy, and speech -language pathology -  that is provided and billed to Medicare contractors.  The Medicare physician  fee schedule (MPFS) is used to make payment for these therapy services at the non facility rate.