American Speech-Language-Hearing Association

CMS Clarifies Rules for Claims-Based Therapy Outcome Reporting

(December 13, 2012)

On December 12, 2012, the Centers for Medicare and Medicaid Services (CMS) held a national provider call that offered additional information and resources for Medicare Part B therapy providers required to report outcomes on the claim forms beginning January 1, 2013, including:

  • The claim form must include two non-payable G-codes representing the current status and a projected goal with the payable service. Each G-code also requires the -GN modifier along with the severity modifier.
  • CMS requires tracking the alpha-numeric G-code and severity modifier in the medical record to comply with documentation requirements.
  • Documentation requirements begin on January 1, including the progress note every 10th treatment day and documentation of patient status. However, compliance with reporting requirements can be phased in; beginning in January, each provider should begin modifying the billing system and start new patients and plans of care that reflect the new documentation requirements. All patients need to be in the reporting cycle so that providers are compliant no later than July 1, 2013.
  • It is acceptable to report the same severity modifier for the current status and projected goal in cases where improvement is expected to be limited.

From the information on the call, ASHA recommends members consider the following:

  • ASHA's National Outcomes Measurement System (NOMS) aligns with the CMS requirements for outcome reporting. Participation in NOMS data collection can assist speech-language pathologists with compliance in reporting and documentation while contributing national-level data to ASHA. Register for NOMS in plenty of time to complete the training. For more information, visit the NOMS website.
  • Begin in January with documentation and phasing in all new patients for the reporting requirements so that claims will not be rejected in July.
  • If a patient has Medicare Part B as a secondary insurance, document the outcome reporting in the medical record. If the primary insurance denies payment, report the outcome on the Medicare claim.

Background

Outcomes reporting on the claim form is a new mandate resulting from the Middle Class Tax Relief and Jobs Creation Act passed in February 2012. Congress required that CMS develop an outcomes reporting mechanism on the claim form for all therapy services. In the final rule, CMS outlines the process for reporting current patient status, projected goals, and discharge status every time an evaluation code is billed, at the "onset of therapy services," at least every 10th treatment day, and at the final visit for the patient under the plan of care. The process includes three non-payable G-codes adopted from seven of the NOMS Functional Communication Measures (FCMs) and one generic set for speech conditions not captured in the seven FCMs.

CMS officials acknowledge outstanding issues that need to be addressed, such as how to report normal evaluations and situations where multiple providers treat an individual beneficiary. Answers will be addressed in the next few weeks in the following CMS sources:

  • Medicare Learning Network, specifically, transmittal MM8005, Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services -Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012
  • National Provider Call Program, which will publish the transcript and slides of the provider call
  • CMS Therapy Services website, which will publish updates and resources as they become available

ASHA Resources

Monitor ASHA's Outpatient Medicare Physician Fee Schedule webpage for updates and new resources; for questions, contact the health care economics and advocacy team at reimbursement@asha.org.


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