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Medical Coding News Archives

Therapy and Functional Limitations for 2013

January 24, 2013:

Nannette Orme, CPC, CCS-P, CPMA, CEMC, Clinical/Technical Editor

Beginning in January 2013, there is a new reporting system for Medicare services required under the Middle Class Tax Relief and Job Creation Act (MCTRJCA) of 2012. This system requires the provider to report data on claims relating to the beneficiary’s function and condition, therapy services furnished, and outcomes attained. These data will enable the Centers for Medicare and Medicaid Services (CMS) to better understand patients’ conditions and outcomes, with the ultimate goal of using the data to help reform the Medicare payment system for outpatient therapy services.

To ensure a trouble-free transition, CMS has instituted a testing period from January 1, 2013, until July 1, 2013. All billers of therapy services are encouraged to begin reporting the new codes and modifiers as soon as they can to address any problems, since noncompliant claims submitted after July 1, 2013, will be returned unpaid.

Nonpayable HCPCS Level II G codes (G8539–G8543) will identify the type of functional limitation being reported and whether it applies to the current status, projected goal status, or discharge status. Modifiers (CH–CN) will be used to indicate the severity and complexity of the functional limitation being tracked. The difference between the reported functional status at the start of therapy and projected goal status represents any progress the therapist anticipates the beneficiary would make during the course of treatment/episode of care.

For the purpose of this requirement, the term “functional limitation” includes both the terms “activity limitations” and “participation restrictions” as described by the International Classification of Functioning, Disability, and Health (ICF). The G codes and associated modifiers are to be reported at the onset of treatment, at least once every 10 treatment days, and at discharge. Documentation in the patient’s medical record must contain the information used for reporting the codes and associated modifiers.

For institutional claims, a charge is required on the service line for each one of these G codes used for functional reporting, even though the codes are not used for purposes of payment. For claims submitted by hospitals, skilled nursing facilities (SNF), rehabilitation agencies, comprehensive outpatient rehabilitation facility (CORF), and home health agencies (HHA), a charge of one penny, $0.01, can be added. For professional claims submitted by private practice therapists and physician/NPPs, a charge of $0.00 (zero charge) can be added.


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