American Speech-Language-Hearing Association

Updated FAQs Change G-code Reporting Rule

(October 31, 2013)

The Centers for Medicare & Medicaid Services (CMS) released an update to their Functional Reporting: PT, OT, and SLP Services Frequently Asked Questions (FAQs) [PDF] that significantly changes the rule restricting reporting to one condition for one date of service.

Question-and-answer 14 has been changed to read:

Q14) How do I report an evaluative procedure when it is for a different functional limitation than I am currently reporting?

A14) You should report the evaluative procedure furnished for a second/different functional limitation other than the primary functional limitation for which ongoing reporting is occurring as a one-time visit (i.e., report all three (3) G-codes in the code set for the functional limitation that most closely matches that for which the evaluative procedure was furnished). The ongoing reporting of a primary functional limitation is not affected when all three (3) G-codes in a code set are reported for the evaluative procedure for a second functional limitation. Note: The reporting of all 3 G-codes for the evaluative procedure for a second functional limitation and the ongoing reporting of a primary functional limitation CAN both occur on the same date of service. [emphasis added]

Further discussion with CMS officials clarified that, if an evaluative procedure is performed on the same date of service for which an ongoing functional condition is reported, the claim should include codes for both sets of functional conditions. Likewise, if two evaluative procedures are billed, each evaluative procedure should include a functional reporting. If one of those evaluative procedures will continue to be reported as the primary condition, the clinician should use the discharge code for the condition that was not deemed to be the primary condition.

Background

The reporting of outcomes on the claim form was mandated in the Middle Class Tax Relief and Jobs Creation Act. Congress required that CMS develop an outcomes reporting mechanism on the claim form for all outpatient therapy services.

Previous instructions limited reporting to one functional condition per date of service, regardless of the number of evaluations performed or any overlap of evaluation of treatment of multiple conditions. CMS subsequently determined that the claims processing system was able to recognize multiple conditions under the same discipline and plan of care.

Although more than one evaluative procedure may now be reported for the same date of service, ongoing reporting is allowed for only one functional limitation (i.e., the primary functional limitation evaluated).

Resources

For more information on the claims-based outcomes reporting requirement, contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at lsatterfield@asha.org.


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