Claims-Based Outcomes Reporting for Medicare Part B Therapy Services

For traditional Medicare, Claims-Based Outcomes Reporting (Functional Limitation Reporting) has ended for any services rendered on or after January 1, 2019. Any Medicare advantage or private plans who chose to adopt Functional Limitation Reporting may elect to continue the program so it is best to check directly with those payers. 

Speech-Language Pathology

Resources for Claims-Based Reporting

The Middle Class Tax Relief and Job Creation Act (MCTRJCA) of 2012 (Pub. L. 112-96) mandated a claims-based data collection strategy for reporting patient condition and outcomes, "designed to assist in reforming the Medicare payment system for outpatient therapy services." Congress and the Centers for Medicare and Medicaid Services (CMS) have been exploring alternatives to therapy payment since the introduction of the therapy caps in 1997.

The implementation date was January 1, 2013. Claims that do not comply with the data reporting requirements will be returned unpaid. All providers of therapy services to Medicare Part B beneficiaries should ensure that they are in full compliance with reporting.

Documentation requirements in the medical record also began January 1, 2013. It is strongly recommended that beneficiaries that have the possibility of transitioning from Medicare Part A to Medicare Part B billing, or Medicare Part B as a secondary insurance, include the G-code and severity modifiers in the medical record with every evaluation and every 10th treatment day, consistent with Medicare guidelines. This will allow for correct reporting on the claim if Medicare Part B services are ever billed.

Who Must Comply?

Anyone providing therapy, including speech-language evaluation and treatment services, for Medicare Part B beneficiaries must report outcomes on the claim form in this mandatory data collection program. This includes Part B services in

  • hospitals,
  • critical access hospitals,
  • private practices,
  • skilled nursing facilities,
  • home health or rehabilitation agencies,
  • outpatient rehabilitation facilities (ORFs), and
  • comprehensive outpatient rehabilitation facilities (CORFs).

Reporting requirements do not apply to Medicare Part A, Medicare Advantage/HMO plans, Medicaid, or private health plans.

How NOMS Can Help

Seven of ASHA's National Outcomes Measurement System (NOMS) Functional Communication Measures were adopted by CMS for speech-language pathology related functional limitations. NOMS uses a similar 7-point scale which can correlate directly with the CMS 7-point severity scale. SLPs are not required to use NOMS for purposes of reporting on the claim form; however, NOMS will assist with

  • selection of appropriate G-code and severity modifiers,
  • fullfilment of the CMS requirement to include a tool or outcome measure to justify determination of severity, and
  • collection of national outcomes that can be used for
    • benchmarking the outcomes of your organization with aggregated national results and
    • identifying changing trends that might affect staffing patterns.

Visit the NOMS website for more information or to sign up.

Other ASHA Resources

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