PT Classroom - Will you be Medicare compliant by July 1st, 2013? ׀ by Chai Rasavong, MPT, MBA

Section 3005(g) of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) requires the Centers for Medicare and Medicaid Services (CMS) to implement “a claims-based 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 Act. Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes (1).” This proposed rule would be applicable for “therapy services (physical therapy, occupational therapy, and speech-language-pathology (SLP)) furnished in hospitals, critical access hospitals (CAHs), skilled nursing facilities (SNFs), CORFs, rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians and nonphysician practitioners (1, 2).”

CMS has an implementation date of January 1, 2013 for this rule with a six month testing period such that claims that do not comply with the data reporting requirements will be returned beginning July 1, 2013 (1). Under this new rule nonpayable G-codes & modifiers will be included on the claim forms to capture data on the beneficiary's functional limitations (1, 2):
A) at the outset of the therapy episode - Initial Evaluation (Current G-code with modifier and Goal G-code with modifier)
B) at a minimum every 10th visit (Current G-code with updated modifier and Goal G-code with modifier (updated))
C) and at discharge (Discharge G-code with modifier and Goal G-code modifier)

G-codes are based on the ICF: Functional limitation = Activity Limitations + Participation Restriction (3). They should be reported in the medical records throughout care at specific intervals when functional reporting is required. When reporting G codes the therapist should report only on one limitation (primary) at a time (3). The therapist is able to report on a second limitation but not simultaneously. The therapist can report a second (subsequent) limitation once reporting of the primary limitation is complete (3). The therapist can initiate reporting of the secondary (subsequent) limitation (New Current G-code with modifier & New Goal G-code with modifier) on the visit following reporting of final status of primary limitation (3)”.

Table 1 - G-Codes for Claims-Based Functional Reporting for 2013

In addition to G-codes, modifiers are to also be included in the medical records which will indicate the extent of the severity/complexity of the functional limitation. These severity modifiers are classified into a seven point scale. Therapist should use valid and reliable functional assessments (ie. Timed Up and Go (TUG), Modified Oswestry Low Back Disability Questionaire, Neck Disability Index (NDI), Disabilities of the Arm, Shoulder, and Hand (DASH), Lower Extremity Functional Scale (LEFS)) and/or objective measures in addition to their clinical judgment in selecting the severity modifier (3). They are to document accordingly in the medical record to justify their choice of modifier and process used. If therapy services are not intended to address a functional limitation use “Other” G-code and the CH modifier (3).

Table 2 - Severity/Complexity Modifiers for 2013

Provided below is a sample guideline for documentation of a patient (s/p L hip ORIF 2 weeks ago) incorporating G codes and severity modifiers (4):

Initial Evaluation
1. Patient completes valid functional tool (Timed Up and Go (TUG), Modified Oswestry Low Back Disability Questionaire, Neck Disability Index (NDI), Disabilities of the Arm, Shoulder, and Hand (DASH), Lower Extremity Functional Scale (LEFS) etc.)
2. Therapist will determine the SEVERITY MODIFIER for the patient’s CURRENT STATUS in the initial evaluation (See Table 2).
3. Therapist will determine the Primary or most significant impairment category “G-CODE” for the patient’s CURRENT STATUS (See Table 1).
4. Therapist will determine the SEVERITY MODIFIER for the GOAL (see Table 2)
5. Therapist will document the supporting medical documentation in the section ASSESSMENT including the Primary CURRENT STATUS “G-Code” and Severity Modifier with the corresponding “G-Code” and GOAL.

 
Initial Evaluation Example:
“Patient’s primary goal for PT is to be able to walk indoors and ascend/descend stairs in home (G8978) independently with use of railing. Her current impairment level is 70% (CL) based on her LEFS and TUG scores. She is expected to be able to walk inside and outside her home with less than 20% (G8979 CI) impairment after 8 weeks of therapy (3).”

10th Visit – Reassessment Note
1. Patient completes valid functional tool (Timed Up and Go (TUG), Modified Oswestry Low Back Disability Questionaire, Neck Disability Index (NDI), Disabilities of the Arm, Shoulder, and Hand (DASH), Lower Extremity Functional Scale (LEFS) etc.)
2. Therapist will determine the SEVERITY MODIFIER for the patient’s CURRENT STATUS at the 10TH Visit (see table 2)
3. Therapist will select the Primary “G-CODE” identified in the Initial Evaluation (See Table 1)
4. Therapist will determine and revise if appropriate the SEVERITY MODIFIER for the patient’s GOAL (See table 2).
5. Therapist will document the supporting medical documentation in the section ASSESSMENT of the Progress Note/Re-Assessment including the Primary “G-Code” and Severity Modifier with the corresponding “G-Code” and GOAL SEVERITY MODIFIER.

10th Visit – Reassessment Example:
"Patient has improved in safety with her mobility. Her current impairment level for walking around (G8978) is 50% (CK) based on her LEFS and TUG scores. She is expected to be able to walk inside and outside her home with less than 20% (G8979 CI) impairment after 8 weeks of therapy (3)."

Discharge
1. Patient completes valid Functional tool (Timed Up and Go (TUG), Modified Oswestry Low Back Disability Questionaire, Neck Disability Index (NDI), Disabilities of the Arm, Shoulder, and Hand (DASH), Lower Extremity Functional Scale (LEFS) etc.)
2. Therapist will determine the SEVERITY MODIFIER for the patient’s CURRENT STATUS at DISCHARGE (see table 2)
3. Therapist will select the Primary “G-CODE” identified in the Initial Evaluation (See Table 1)
4. Therapist will determine and revise if appropriate the SEVERITY MODIFIER for the patient’s GOAL (see table 2).
5. Therapist will document the supporting medical documentation in the section of ASSESSMENT the Discharge Summary including the Primary “G-Code” and Severity Modifier with the corresponding “G-Code” and
GOAL SEVERITY MODIFIER. (See tables 1 & 2)
* If the Primary Impairment goal has been met, therapist may begin reporting on the next significant impairment.

Discharge – Reassessment Example:
"Patient has improved in safety with her mobility. Her current impairment level for walking around (G8980) is 15% (CI) based on her LEFS and TUG scores. She has achieved her goal to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy (3)."

Last revised: February 17, 2013
by Chai Rasavong, MPT, MBA