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.
October 31, 2013: Updated Guidance from CMS
- New Guidance! Each evaluation should include functional reporting. 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.
- New Guidance! Multiple evaluations performed on the same date of service should include functional reporting, according to the condition evaluated with the procedure. If one of those conditions 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. 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).
On Monday, a patient is seen for a motor speech and swallowing evaluation. CPT codes 92506 and 92610 are billed. The clinician decides that motor speech will be the functional limitation reported on an ongoing basis. On the claim for Monday, the current status and the projected goal will be reported for motor speech and the current status, projected goal, and discharge status will all be reported for swallowing. The clinician would then continue reporting every 10th treatment day for the motor speech functional limitation, even though he/she may also be treating the swallowing disorder simultaneously.
A patient with a motor speech impairment was referred for treatment and the clinician begins functional outcomes reporting for motor speech. After several sessions, the clinician observes that the patient is also having difficulty swallowing, so a swallowing evaluation is scheduled on the same day the patient comes in for their regular treatment session. Coincidentally, the swallowing evaluation occurs on the 10th treatment day for the motor speech functional limitation, when the regular G-code reporting is due. The claim for that date of service includes 92507 for the motor speech treatment and 92610 for the swallowing evaluation. The clinician includes the current status and projected goal for the motor speech functional limitation and reports the swallowing functional limitation with the current status, projected goal, and discharge status.
- 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 date of service that an evaluation code is billed, and every 10th treatment day.
- Ongoing 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.
- Report 2 non-payable G-codes every time reporting is required. The primary long‐term treatment goals should be reported with the current patient status, including for each date of service that 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.
- Observation Status: Observation services are, by Medicare's definition, outpatient services in the hospital. As such, functional reporting applies. Once the decision is made to admit the beneficiary to the inpatient hospital, functional reporting no longer applies. If the beneficiary's treatment was furnished on just one date of service, the therapist would report all three G-codes in the set for the functional limitation being reported.
- New Guidance! Multiple Evaluations: Multiple evaluations performed on the same date of service for different functional limitations should be reported and the G-codes should correspond to the evaluation performed. For evaluations that occur during the course of treatment for a different functional limitation (e.g., the primary condition treated and reported is related to cognition but a modified barium swallow study is performed), the evaluation is reported as a one-time visit (i.e., report all three 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 by the reporting of a one-time visit, and reporting should continue with the 10th treatment day reporting interval.
- Documentation requirements begin January 1, 2013, and include a progress note every 10th 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.
- Documentation must justify the condition(s) reported on the claim.
- Beginning July 1, 2013, claims without correct reporting of the G-codes and severity modifiers will be stopped prior to adjudication and returned undpaid. This is not a denial of service.
- 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.