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December 19, 2014

Claims-Based Data Collection Requirement for Outpatient Therapy Services

This reporting and collection system requires claims for therapy services to include non-payable G-codes and related modifiers. These non-payable G-codes and severity/complexity modifiers provide information about the beneficiary’s functional status at:

  • The outset of the therapy episode of care,
  • Specified points during treatment, and
  • The time of discharge

This functional data reporting and collection system was effective for therapy services with dates of service on and after January 1, 2013.

Because these are non-payable G-codes, there will be no Relative Value Units or payment amounts for these codes.

Services Affected  Applies to all claims for services furnished under the Medicare Part B outpatient therapy benefit and the Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services furnished under the Comprehensive Outpatient Rehabilitation Facility (CORF) benefit. They also apply to the therapy services furnished incident to the service of a physician and certain Non-Physician Practitioners (NPPs), including, Nurse Practitioners (NPs), Certified Nurse Specialists (CNSs), and Physician Assistants (PAs).

Providers and Practitioners Affected  These reporting requirements apply to the therapy services furnished by the following providers and practitioners:

  • Hospitals
  • Critical Access Hospitals (CAHs)
  • Skilled Nursing Facilities (SNFs)
  • Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  • Rehabilitation agencies
  • Home Health Agencies (HHAs) (when the beneficiary is not under a home health plan of care)
  • Therapists in Private Practice (TPPs)
  • Physicians
  • Non-Physician Practitioners (NPPs)

Function-Related G-Codes
The following Healthcare Common Procedure Coding System (HCPCS) G-codes are used to report the status of a beneficiary’s functional limitations:

G-Code Set

HCPCS Code

Description

Mobility G-code set

G8978

Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals.

G8979

Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8980

Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting.

Changing & Maintaining Body Position G-code set

G8981

Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals.

G8982

Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8983

Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting.

Carrying, Moving & Handling Objects G-code set

G8984

Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals

G8985

Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8986

Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting

Self Care G-code Set

G8987

Self care functional limitation, current status, at therapy episode outset and at reporting intervals

G8988

Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8989

Self care functional limitation, discharge status, at discharge from therapy or to end reporting

Other PT/OT Primary G-code Set

G8990

Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals

G8991

Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8992

Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting

Other PT/OT Subsequent G-code Set

G8993

Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals

G8994

Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting

G8995

Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting

Swallowing G-code Set

G8996

Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G8997

Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy

G8998

Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation

Motor Speech G-code Set

G8999

Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9186

Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9158

Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Spoken Language Comprehension G-code Set

G9159

Spoken language comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9160

Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9161

Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Spoken Language Expressive G-code Set

G9162

Spoken language expression functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9163

Spoken language expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9164

Spoken language expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Attention G-code Set

G9165

Attention functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9166

Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9167

Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Memory G-code Set

G9168

Memory functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9169

Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9170

Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Voice G-code Set

G9171

Voice functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9172

Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9173

Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Other Speech Language Pathology G-code Set

G9174

Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals

G9175

Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy

G9176

Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation

Severity/Complexity Modifiers
For each non-payable HCPCS G-code shown above, a modifier must be used to report the severity/complexity for that functional measure. The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the therapist, physician, or NPP furnishing the therapy services. The beneficiary’s current status, the anticipated goal status, and the discharge status are reported via the appropriate severity modifiers.

HCPCS 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 restricted

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

Reporting Tips

  • Functional reporting is required for certain dates of service
    • At the outset of a therapy episode of care
    • At least once every 10 treatment days
    • The same date of service of an evaluative/re-evaluative  procedure
       

      CPT Codes Requiring Functional G-codes and Modifiers

      92506

      92597

      92607

      92608

      92610

      92611

      92612

      92614

      92616

      96105

      96125

      97001

      97002

      97003

      97004

    • At the time of discharge from the therapy episode of care
    • On the same date of service the reporting of a particular functional limitation in ended, in cases where the need for further therapy is necessary
  • 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 HCPCS G-codes AFTER the first reported functional limitation is complete.
  • 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
      • Exception:
        • May report more than two G-codes when a patient is receiving therapy services under multiple plans of care from the same provider
        • One-time therapy where future therapy is not medically indicated or going to be furnished by a different provider.  In this case, all three G-codes (current/goal/discharge status) and a corresponding modifier are reported.
  • All G-codes and modifiers reported must be supported in the medical record
  • The non-payable G-codes must be reported with TWO modifiers
    • The severity modifier
      • HCPCS modifiers CH-CN
    • The appropriate therapy modifier. (Note: therapy modifiers are also required on the payable therapy services.) 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
  • The non-payable HCPCS G-codes must also contain the following information
    • The same date of corresponding billable service
    • Nominal charge (either $0.00 or $0.01)

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