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Revision: February 19, 2014

February 14, 2014

Functional Reporting for Outpatient Therapy Services: Reminders

Functional data reporting and collection requirements were implemented as of July 1, 2013, for outpatient therapy service claims with dates of service on or after January 1, 2013. This means that new HCPCS codes and modifiers describing functional limitations and severity for patients are required for outpatient therapy services, including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services. This system is designed to collect data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures.

Beneficiary function information is reported using 42 non-payable functional HCPCS G-codes and seven severity/complexity modifiers on claims for PT, OT, and SLP services. Functional reporting on one functional limitation at a time is required periodically throughout an entire PT, OT, or SLP therapy episode of care.

The following are reminders on the functional reporting process:

  • Functional status is required at very specific intervals
    • At the outset of the therapy episode of care
    • At specific points during treatment
      • Once every 10 treatment days
      • The same date of service of an evaluative/re-evaluative service
    • At the time of discharge for the plan of care
  • Generally, two G-codes will be reported at a time
    • One G-code for current status (e.g., HCPCS code G8978)
    • A second G-code for projected goal status (e.g., HCPCS code G8979)
      • Report the discharge code (e.g., HCPCS code G8980) ONLY at the end of the limitation reporting period.
      • Reporting this G-code out of sequence may result in subsequent services being denied
        • At the end of a reporting period, report the projected goal status (e.g., HCPCS code G8979) and the discharge (e.g., HCPCS code G8980) G-codes
  • Report only ONE functional limitation at a given time.
    • If a patient has more than one plan of care, report on the second functional limitation using a different set of G-codes AFTER the first reported functional limitation is complete.
  • The non-payable G-codes must be reported with TWO modifiers: the new severity modifier (HCPCS modifiers CH-CN) and the appropriate therapy modifier. (Note: therapy modifiers are also required on the payable therapy services as well.) The therapy modifiers are:
    • HCPCS modifier GN – Service delivered under an Outpatient Speech-Language Pathology Plan of Care
    • HCPCS modifier GO – Service delivered under an Occupational Therapy Plan of Care
    • HCPCS modifier GP – Service delivered under an Outpatient Physical Therapy Plan of Care
  • Selection of the severity/complexity modifier is determined by the therapist, physician or non-physician practitioner (NPP)

Reporting functional limitation G-codes in the correct sequence and at the proper interval is critical to the adjudication of your claims. For more details on the process and an example of correct reporting, please refer to MLN Matters article MM8005External PDF. You can also find an example of correct reporting on page 19 of change request (CR) 8482External PDF. The table used in the example (as shown in the CR) may help to track functional G-codes submitted to CGS and ensure they are being reported in the correct sequence.

If you need assistance, please call our Provider Contact Center at 866.276.9558.

Check here for the handout and Q&As from a teleconference held November 2014.

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