Functional Reporting

10.6 - Functional Reporting (Rev. 4214, Issued: 01-25-19, Effective: 01-01-19, Implementation: 02-26-19) A. General Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Act to require a claims-based data collection system for outpatient therapy services, including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services. 42 CFR 410.59, 410.60, 410.61, 410.62 and 410.105 implement this requirement. The system will collect data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures. Beneficiary function information is reported using 42 nonpayable functional G-codes and seven severity/complexity modifiers on claims for PT, OT, and SLP services. Functional reporting on one functional limitation at a time is required periodically throughout an entire PT, OT, or SLP therapy episode of care. The nonpayable G-codes and severity modifiers provide information about the beneficiary’s functional status at the outset of the therapy episode of care, including projected goal status, at specified points during treatment, and at the time of discharge. These G-codes, along with the associated modifiers, are required at specified intervals on all claims for outpatient therapy services – not just those over the cap. In the CY 2019 Physician Fee Schedule final rule, CMS-1693-F, after consideration of stakeholders’ requests for burden reduction, a review of all of the MCTRJCA requirements, and in light of the statutory amendments to section 1833(g) of the Act, via section 50202 of Bipartisan Budget Act of 2018 to repeal the therapy caps, CMS concluded that continued collection of functional reporting data through the same format would not yield additional information to inform future analyses or to serve as a basis for reforms to the payment system for therapy services. The rule ended the functional reporting requirements to reduce burden of reporting for providers of therapy services and revised regulation text at 42 CFR 410.59, 410.60, 410.61, 410.62, 410.105, accordingly. The instructions below apply only to dates of service when the reporting requirement was effective, January 1, 2013 through December 31, 2018. B. Application of Coding Requirements This functional data reporting and collection system is effective for therapy services with dates of service on and after January 1, 2013 and before January 1, 2019. C. Services Affected These requirements apply to all claims for services furnished under the Medicare Part B outpatient therapy benefit and the PT, OT, and SLP services furnished under the CORF benefit. They also apply to the therapy services furnished personally by and incident to the service of a physician or a nonphysician practitioner (NPP), including a nurse practitioner (NP), a certified nurse specialist (CNS), or a physician assistant (PA), as applicable. D. Providers and Practitioners Affected. The functional reporting requirements apply to the therapy services furnished by the following providers: hospitals, CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (when the beneficiary is not under a home health plan of care). It applies to the following practitioners: physical therapists, occupational therapists, and speech-language pathologists in private practice (TPPs), physicians, and NPPs as noted above. The term “clinician” is applied to these practitioners throughout this manual section. (See definition section of Pub. 100-02, Chapter 15, section 220.) E. Function-related G-codes There are 42 functional G-codes, 14 sets of three codes each. Six of the G-code sets are generally for PT and OT functional limitations and eight sets of G-codes are for SLP functional limitations. The following G-codes are for functional limitations typically seen in beneficiaries receiving PT or OT services. The first four of these sets describe categories of functional limitations and the final two sets describe “other” functional limitations, which are to be used for functional limitations not described by one of the four categories. NONPAYABLE G-CODES FOR FUNCTIONAL LIMITATIONS Code Long Descriptor Short Descriptor Mobility G-code Set G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility current status G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility goal status G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Mobility D/C status Changing & Maintaining Body Position G-code Set G8981 Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Body pos current status G8982 Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Body pos goal status G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Body pos D/C status Carrying, Moving & Handling Objects G-code Set G8984 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carry current status G8985 Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carry goal status G8986 Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Carry D/C status Self Care G-code Set G8987 Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care current status G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care goal status G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting Self care D/C status The following “other PT/OT” functional G-codes are used to report: • a beneficiary’s functional limitation that is not defined by one of the above four categories; • a beneficiary whose therapy services are not intended to treat a functional limitation; • or a beneficiary’s functional limitation when an overall, composite or other score from a functional assessment too is used and it does not clearly represent a functional limitation defined by one of the above four code sets. Code Long Descriptor Short Descriptor Other PT/OT Primary G-code Set G8990 Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other PT/OT current status Code Long Descriptor Short Descriptor G8991 Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other PT/OT goal status G8992 Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other PT/OT D/C status Other PT/OT Subsequent G-code Set G8993 Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Sub PT/OT current status G8994 Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Sub PT/OT goal status G8995 Other physical or occupational subsequent functional limitation, discharge from therapy or end reporting. Sub PT/OT D/C status The following G-codes are for functional limitations typically seen in beneficiaries receiving SLP services. Seven are for specific functional communication measures, which are modeled after the National Outcomes Measurement System (NOMS), and one is for any “other” measure not described by one of the other seven. Code Long Descriptor Short Descriptor Swallowing G-code Set G8996 Swallowing functional limitation, current status, at therapy episode outset and at reporting intervals Swallow current status G8997 Swallowing functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Swallow goal status G8998 Swallowing functional limitation, discharge status, at discharge from therapy or to end reporting Swallow D/C status Motor Speech G-code Set (Note: These codes are not sequentially numbered) G8999 Motor speech functional limitation, current status, at therapy episode outset and at reporting intervals Motor speech current status G9186 Motor speech functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting Motor speech goal status Code Long Descriptor Short Descriptor G9158 Motor speech functional limitation, discharge status, at discharge from therapy or to end reporting Motor speech D/C status Spoken Language Comprehension G-code Set G9159 Spoken language comprehension functional limitation, current status, at therapy episode outset and at reporting intervals Lang comp current status G9160 Spoken language comprehension functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Lang comp goal status G9161 Spoken language comprehension functional limitation, discharge status, at discharge from therapy or to end reporting Lang comp D/C status Spoken Language Expressive G-code Set G9162 Spoken language expression functional limitation, current status, at therapy episode outset and at reporting intervals Lang express current status G9163 Spoken language expression functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Lang press goal status G9164 Spoken language expression functional limitation, discharge status, at discharge from therapy or to end reporting Lang express D/C status Attention G-code Set G9165 Attention functional limitation, current status, at therapy episode outset and at reporting intervals Atten current status G9166 Attention functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Atten goal status G9167 Attention functional limitation, discharge status, at discharge from therapy or to end reporting Atten D/C status Memory G-code Set G9168 Memory functional limitation, current status, at therapy episode outset and at reporting intervals Memory current status G9169 Memory functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Memory goal status G9170 Memory functional limitation, discharge status, at discharge from therapy or to end reporting Memory D/C status Voice G-code Set G9171 Voice functional limitation, current status, at therapy episode outset and at reporting intervals Voice current status Code Long Descriptor Short Descriptor G9172 Voice functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Voice goal status G9173 Voice functional limitation, discharge status, at discharge from therapy or to end reporting Voice D/C status The following “other SLP” G-code set is used to report: • on one of the other eight NOMS-defined functional measures not described by the above code sets; or • to report an overall, composite or other score from assessment tool that does not clearly represent one of the above seven categorical SLP functional measures. Code Long Descriptor Short Descriptor Other Speech Language Pathology G-code Set G9174 Other speech language pathology functional limitation, current status, at therapy episode outset and at reporting intervals Speech lang current status G9175 Other speech language pathology functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Speech lang goal status G9176 Other speech language pathology functional limitation, discharge status, at discharge from therapy or to end reporting Speech lang D/C status F. Severity/Complexity Modifiers For each nonpayable functional G-code, one of the modifiers listed below must be used to report the severity/complexity for that functional limitation. Modifier Impairment Limitation Restriction CH 0 percent impaired, limited or restricted CI At least 1 percent but less than 20 percent impaired, limited or restricted CJ At least 20 percent but less than 40 percent impaired, limited or restricted CK At least 40 percent but less than 60 percent impaired, limited or restricted CL At least 60 percent but less than 80 percent impaired, limited or restricted CM At least 80 percent but less than 100 percent impaired, limited or restricted CN 100 percent impaired, limited or restricted The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services. G. Required Reporting of Functional G-codes and Severity Modifiers The functional G-codes and severity modifiers listed above are used in the required reporting on therapy claims at certain specified points during therapy episodes of care. Claims containing these functional G-codes must also contain another billable and separately payable (non-bundled) service. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC). Functional reporting using the G-codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims: • At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service); • At least once every 10 treatment days, which corresponds with the progress reporting period; • When an evaluative procedure, including a re-evaluative one, ( HCPCS/CPT codes 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97161, 97162 ,97163, 97164, 97165, 97166, 97167, 97168) is furnished and billed; • At the time of discharge from the therapy episode of care–(i.e., on the date services related to the discharge [progress] report are furnished); and • At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is necessary. • At the time reporting is begun for a new or different functional limitation within the same episode of care (i.e., after the reporting of the prior functional limitation is ended) Functional reporting is required on claims throughout the entire episode of care. When the beneficiary has reached his or her goal or progress has been maximized on the initially selected functional limitation, but the need for treatment continues, reporting is required for a second functional limitation using another set of G-codes. In these situations two or more functional limitations will be reported for a beneficiary during the therapy episode of care. Thus, reporting on more than one functional limitation may be required for some beneficiaries but not simultaneously. When the beneficiary stops coming to therapy prior to discharge, the clinician should report the functional information on the last claim. If the clinician is unaware that the beneficiary is not returning for therapy until after the last claim is submitted, the clinician cannot report the discharge status. When functional reporting is required on a claim for therapy services, two G-codes will generally be required. Two exceptions exist: 1. Therapy services under more than one therapy POC-- Claims may contain more than two nonpayable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider. 2. One-Time Therapy Visit-- When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G- codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers. Each reported functional G-code must also contain the following line of service information: • Functional severity modifier • Therapy modifier indicating the related discipline/POC -- GP, GO or GN -- for PT, OT, and SLP services, respectively • Date of the related therapy service • Nominal charge, e.g., a penny, for institutional claims submitted to the A/B MACs (A). For professional claims, a zero charge is acceptable for the service line. If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included. NOTE: The KX modifier is not required on the claim line for nonpayable G-codes, but would be required with the procedure code for medically necessary therapy services furnished once the beneficiary’s annual cap has been reached. The following example demonstrates how the G-codes and modifiers are used. In this example, the clinician determines that the beneficiary’s mobility restriction is the most clinically relevant functional limitation and selects the Mobility G-code set (G8978 – G8980) to represent the beneficiary’s functional limitation. The clinician also determines the severity/complexity of the beneficiary’s functional limitation and selects the appropriate modifier. In this example, the clinician determines that the beneficiary has a 75 percent mobility restriction for which the CL modifier is applicable. The clinician expects that at the end of therapy the beneficiaries will have only a 15 percent mobility restriction for which the CI modifier is applicable. When the beneficiary attains the mobility goal, therapy continues to be medically necessary to address a functional limitation for which there is no categorical G-code. The clinician reports this using (G8990 – G8992). At the outset of therapy-- On the DOS for which the initial evaluative procedure is furnished or the initial treatment day of a therapy POC, the claim for the service will also include two G-codes as shown below. • G8978-CL to report the functional limitation (Mobility with current mobility limitation of “at least 60 percent but less than 80 percent impaired, limited or restricted”) • G8979-CI to report the projected goal for a mobility restriction of “at least 1 percent but less than 20 percent impaired, limited or restricted.” At the end of each progress reporting period-- On the claim for the DOS when the services related to the progress report (which must be done at least once each 10 treatment days) are furnished, the clinician will report the same two G-codes but the modifier for the current status may be different. • G8978 with the appropriate modifier are reported to show the beneficiary’s current status as of this DOS. So if the beneficiary has made no progress, this claim will include G8978-CL. If the beneficiary made progress and now has a mobility restriction of 65 percent CL would still be the appropriate modifier for 65 percent, and G8978-CL would be reported in this case. If the beneficiary now has a mobility restriction of 45 percent, G8978-CK would be reported. • G8979-CI would be reported to show the projected goal. This severity modifier would not change unless the clinician adjusts the beneficiary’s goal. This step is repeated as necessary and clinically appropriate, adjusting the current status modifier used as the beneficiary progresses through therapy. At the time the beneficiary is discharged from the therapy episode. The final claim for therapy episode will include two G-codes. • G8979-CI would be reported to show the projected goal. G8980-CI would be reported if the beneficiary attained the 15 percent mobility goal. Alternatively, if the beneficiary’s mobility restriction only reached 25 percent; G8980-CJ would be reported. To end reporting of one functional limitation-- As noted above, functional reporting is required to continue throughout the entire episode of care. Accordingly, when further therapy is medically necessary after the beneficiary attains the goal for the first reported functional limitation, the clinician would end reporting of the first functional limitation by using the same G-codes and modifiers that would be used at the time of discharge. Using the mobility example, to end reporting of the mobility functional limitation, G8979-CI and G8980-CI would be reported on the same DOS that coincides with end of that progress reporting period. To begin reporting of a second functional limitation. At the time reporting is begun for a new and different functional limitation, within the same episode of care (i.e., after the reporting of the prior functional limitation is ended). Reporting on the second functional limitation, however, is not begun until the DOS of the next treatment day -- which is day one of the new progress reporting period. When the next functional limitation to be reported is NOT defined by one of the other three PT/OT categorical codes, the G-code set (G8990 - G8992) for the “other PT/OT primary” functional limitation is used, rather than the G-code set for the “other PT/OT subsequent” because it is the first reported “other PT/OT” functional limitation. This reporting begins on the DOS of the first treatment day following the mobility “discharge” reporting, which is counted as the initial service for the “other PT/OT primary” functional limitation and the first treatment day of the new progress reporting period. In this case, G8990 and G8991, along with the corresponding modifiers, are reported on the claim for therapy services. The table below illustrates when reporting is required using this example and what G- codes would be used. Example of Required Reporting Key: Reporting Period (RP) Begin RP #1 for Mobility at Episode Outset End RP#1for Mobility at Progress Report Mobility RP #2 Begins Next Treatment Day End RP #2 for Mobility at Progress Report Mobility RP #3 Begins Next Treatment Day D/C or End Reporting for Mobility Begin RP #1 for Other PT/OT Primary Mobility: Walking & Moving Around G8978 – Current Status X X X G 8979– Goal Status X X X X G8980 – Discharge Status X Other PT/OT Primary G8990 – Current Status X G8991 – Goal Status X G8992 – Discharge Status No Functional Reporting Required X X H. Required Tracking and Documentation of Functional G-codes and Severity Modifiers The clinician who furnishes the services must not only report the functional information on the therapy claim, but, he/she must track and document the G-codes and severity modifiers used for this reporting in the beneficiary’s medical record of therapy services. For details related to the documentation requirements, refer to, Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, section 220.4 - Functional Reporting. For coverage rules related to MCTRJCA and therapy goals, refer to Pub. 100-02: a) for outpatient therapy services, see Chapter 15, section 220.1.2 B and b) for instructions specific to PT, OT, and SLP services in the CORF, see Chapter 12, section 10.