Guidance on Claims-Based Outcomes Reporting for Medicare Part B Therapy Services

Centers for Medicare and Medicaid Services (CMS)

The following is a summary of guidance and instructions from CMS as they relate to claims-based outcomes reporting for Medicare Part B therapy services. Additional guidance and links to CMS resources will be added here as they become available.

Reporting

• Reporting is required for all therapy services, not just services above the therapy cap.
• If a patient is seen by more than one discipline, each discipline should report the status and severity for their plan of care.
• Reporting should occur at the first visit (including evaluation), discharge, every time an evaluation code is billed, and every 10th treatment day.
• Reporting (but not treatment) is limited to one condition/disorder/functional limitation at a time, even for those patients who qualify and will be treated for multiple categories. The primary functional limitation should be chosen, and, after the treatment goal is achieved for the primary, a subsequent functional limitation should be reported.  Do not report multiple conditions at the same time - this is incorrect and will result in claims being returned unpaid.
• Report 2 non-payable G-codes every time reporting is required. The primary long‐term treatment goals should be reported with the patient status, including each time an evaluation code is billed, using the appropriate G‐code and severity modifier. The discharge status is reported on the last visit with the primary long-term treatment goal.
• Discharge reporting is required, except for those cases where therapy services are discontinued by the beneficiary prior to the planned discharge visit and the claim was submitted prior to that knowledge.
• One-Time Therapy Visit: For cases where the evaluation indicates therapy is not necessary, or a referral is made to another provider for therapy services, all three G-codes (current status, goal status and discharge status) with corresponding severity modifiers is reported for the primary condition.

Documentation

• Documentation requirements begin January 1, 2013, and include a progress note every 10^th treatment day.
• The alpha‐numeric G‐codes and the related modifiers must be documented in the beneficiary's medical record, also with the tool and/or justification of how the severity modifier was determined with every progress note.
• It is acceptable to document and report the same severity modifier for the current status and goal when the improvement is expected to be limited, or for those individuals receiving maintenance therapy.

Claim Form

• Prior to July 1, 2013, all current therapy patients should have started the reporting cycle with the G-codes added to the claim for therapy services and documented in the medical record.
• The therapy modifier -GN is required on the claim form to indicate the therapy service is furnished under the SLP plan of care. The -GN modifier is also required for all of the G‐codes reported on the claim.
• For each line of the institutional claim, a charge of $0.01 should be added for the non‐payable G‐code. For each line of the professional claim submitted by private practice providers, a charge of $0.00 or $0.01 should be added, depending on the requirements of your billing system.
• Claims must have a payable code for processing, so reporting must be accompanied by a furnished service. Do not submit a claim with only the non‐payable G‐codes.
• Services over the therapy cap of $1900 require the -KX modifier. However, the -KX modifier should not accompany the non‐payable G‐code, only the billable service.
• Medicare will return a Claim Adjustment Reason Code 246 (This non-payable code is for required reporting only) and a Group Code of CO (Contractual Obligation) assigning financial liability to the provider. In addition, beneficiaries will be informed via Medicare Summary Notice 36.7 that they are not responsible for any charge amount associated with one of these G-codes.

CMS Resources

• Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services [PDF]
• CMS Therapy Services Website
• Medicare Benefit Policy Manual: Chapter 15 [PDF]

ASHA Resources

• G-Codes and Severity Modifier Lists
• Case Scenarios and Sample Claim Form Entries for Outcomes Reporting [PDF]
• Overview of Claims-Based Outcomes Reporting Requirement for Therapy Services
• Replay of ASHA Online Chat on Medicare Therapy G-Codes Basics
• Medicare Coverage of Speech-Language Pathologists & Audiologists