The Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA; for more information, see http://www.gpo.gov/fdsys/pkg/CRPT-112hrpt399/pdf/CRPT-112hrpt399.pdf ) states: “The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes.”
This claims-based data collection system is being implemented to include both 1) the reporting of data by the SNF and the therapists furnishing the therapy services, and 2) the collection of data by the Medicare Administrative Contractors (MACs). This reporting and collection system requires claims for therapy services to include non-payable G-Codes and related modifiers. The non-payable G-Codes and severity/complexity modifiers will provide information about the patient’s functional status at:
- The outset of the therapy episode of care,
- Specified points during treatment (i.e., at least once every 10 treatment days), and
- The time of discharge.
These G-codes and related modifiers are required on all Part B claims provided to residents in our SNF and/or to patients visiting our outpatient treatment centers, regardless of their Part B cap or threshold status.
The functional data reporting and collection system is effective for therapy services with dates of service on or after January 1, 2013. The testing period is in effect until June 30, 2013, to allow us to use the new coding requirements with our Rehab Optima (RO) and Point Click Care (PCC) systems in order to assure that they work. During this testing period, the MACs will continue to process Part B claims without the G-Codes and modifiers. However, claims with therapy services on and after July 1, 2013, will be rejected if they do not contain the required functional G-Code/modifier information.
There are a total of 42 different G-Codes broken down into the following 14 subsections, each including status codes for current status, goal status and discontinuation status:
- Mobility
- Changing and Maintaining Body Position
- Carrying, Moving and Handling Objects
- Self Care
- Other PT/OT Primary
- Other PT/OT Subsequent
- Swallowing
- Motor Speech
- Spoken Language Comprehension
- Spoken Language Expressive
- Attention
- Memory
- Voice
- Other Speech-Language Pathology
The Severity/Complexity Modifiers reflect the patient’s percentage of functional impairment as determined by the therapist, physician or non-physician practitioner (NPP) furnishing the therapy services. The patient’s current status, anticipated goal status and the discharge status are reported using the appropriate severity modifiers. The seven modifiers are defined below:
|
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 functional G-Codes and corresponding severity modifiers listed above must be used on the therapy claims beginning July 1, 2013. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC). However, functional reporting is required on claims throughout the entire episode of care. This means there will be instances where two or more functional limitations will be reported for one patient’s POC, just not during the same time frame. In these situations, where reporting on the first functional limitation is complete and the need for treatment continues, reporting will be required for a second functional limitation using another set of G-Codes. So, the claim may demonstrate a status on more than one functional limitation for a single POC, but the claims would not be used simultaneously.
Rehab Optima has integrated this new functional reporting system into the case manager console, which makes the system very accessible to therapists. In addition, hotlist monitoring has also been added to help with the day-to-day management of the functional G-Code reporting process. Your therapy resource team is testing the new tools and the integration with PCC. We have recorded our Webex trainings from March 26, 2013, so ask your therapy resource if you did not receive the link. The trainings will also be added to our Learning Management System (Brainshark) for those that were unable to attend the Webex. The availability of the functional G-code reporting system is set to go live in Rehab Optima for our facilities beginning April 1, 2013. This will allow our therapists sufficient time to practice using the functional G-codes prior to the July 1, 2013, required date.
If you are interested in reading further about the Functional Reporting System, be sure to check out Medicare Learning Network Matters Number MM8005 on the www.cms.gov website or contact your therapy resource.