Therapy Functional Reporting. Part A Provider Outreach and Education March 2016

Transcription

1 Therapy Functional Reporting Part A Provider Outreach and Education March 2016

2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. March

3 Agenda Reporting Functional Therapy Codes and Modifiers Discharge Reporting Documentation Requirements March

4 Helpful Acronyms CAH CARC CCI CERT CORF CPT HIPAA IOM Critical Access Hospital Claim Adjustment Reason Code Correct Coding Initiative Comprehensive Error Rate Testing Comprehensive Outpatient Rehabilitation Facilities Current Procedural Terminology Health Insurance Portability & Accountability Act Internet Only Manual March

5 Helpful Acronyms LCD MLN NCD POC RARC SNF Local Coverage Determination Medicare Learning Network National Coverage Determination Plan of Care Remittance Advice Remark Code Skilled Nursing Facility March

6 Objective Provide an explanation of the guidelines for data collection as outlined in the Internet Only Manuals (IOM) and MLN Articles Experience and best practices collected since the reporting requirement began Cover the questions most often asked March

7 Functional Reporting

8 Functional Reporting Services Therapy services furnished under Medicare Part B Physical Therapists (PT), Occupational Therapists (OT), Speech Language Pathologists (SLP) in Comprehensive Outpatient Rehabilitation Facilities (CORF) Therapy service furnished personally and incident to physicians and certain Nonphysician Practitioners (NPPs) March

9 Professional Affected Functional Data collection applies to Physical Therapists, Occupational Therapists, Speech Language Pathologists Medical Doctors (MDs), Doctors of Osteopathy (DOs), Doctors of Podiatric Medicine (DPMs), Doctors of Optometry (ODs) Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Physician Assistants (PAs) March

10 Providers Affected Functional reporting applies to Hospital outpatient departments and inpatients receiving Part B services Type of Bill (TOB) 12X, 13X Critical Access Hospitals (CAH) TOB 85X Skilled Nursing Facilities (SNF) TOB 22X, 23X, March

11 Provider Affected 2 Functional reporting applies to Outpatient Rehabilitation Facilities (ORF) TOB 74X Comprehensive Outpatient Rehabilitation Facilities (CORF) TOB 75X Home Health (HH) Agencies Therapy service not paid under the Home Health Prospective Payment System Not under a HH plan of care and not homebound TOB 34X March

12 Functional Reporting Coding Requirements G- codes and Severity/Complexity Modifiers

13 Claim Data for Outpatient Therapy Services Reporting of 42 non-payable G-codes 14 sets of 3 codes (current, projected, discharge status) 7 severity modifiers required for PT, OT, SLP services Percentage of functional level MPFSDB status indicator Q therapy functional information code March

14 Functional G-Codes and Severity/Complexity Modifiers JE Therapy Non-payable HCPCS codes JF Therapy Non-payable HCPCS codes CMS Quick Reference Chart - download Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/G-Codes- Chart pdf March

15 Impairment Limitation Restriction Modifiers MODIFIER CH CI CJ CK CL CM CN IMPAIRMENT LIMIATION RESTRICTION 0 percent (%) impaired, limited or restricted At least 1 % but less than 20% impaired, limited or restricted At least 20 % but less than 40% impaired, limited or restricted At least 40 % but less than 60% impaired, limited or restricted At least 60% but less than 80% impaired, limited or restricted At least 80% but less than 100% impaired, limited or restricted 100% impaired, limited or restricted March

16 Selecting Functional G-Codes Reflect the predominant limitation that the furnished therapy services are intended to address Primary functional limitation being treated or Primary reason for treatment More than one limitation? the therapist may need to make a determination as to which functional limitation is primary March

17 Selecting Severity/Complexity Modifiers Use the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat a functional limitation Use the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument March

18 Selecting Severity/Complexity Modifiers 2 Therapists can use their clinical judgment in the assignment of the appropriate modifier Document in the medical record how the modifier selection was made the same process can be followed at succeeding assessment intervals March

19 Reporting Frequency Outset of therapy episode of care Date of service for the initial therapy claim Once every 10 treatment days When progress report finished At the time of discharge from therapy episode of care or functional reporting period Unless data is not available March

20 Reporting Requirements Reporting episode Period of time based on dates of service May contain more than one reporting period Per patient, therapy discipline and NPI Reporting period Same as progress reporting Time from first functional coding to the 10th treatment day March

21 Discharge Reporting Discharge is required From therapy reporting episode or To end reporting one functional limitation before reporting a different limitation Beneficiary discontinues therapy during a reporting episode Document in the discharge note or summary the final services February

22 Discharge Reporting 2 Provider did not bill a discharge claim Beneficiary returns to same NPI provider; less than 60 calendar days Actions to take Resume same functional limitation reporting; use the same G-code set or Start different functional limitation; discharge previous reporting March

23 Discharge Reporting 3 Once one functional limitation is discharged report next functional limitation on the next date of service Further therapy must be medically necessary Reporting episode automatically discharges after 60 or more calendar days From last recorded date of service March

24 Functional Therapy Codes and Severity Modifiers Functional Reporting required Non-payable G-code used to report functional limitation Modifier used to report severity level for the functional limitation Claims will not process Without applicable G-codes and severity modifiers Without appropriate code sets per episode of care March

25 Reporting Requirements Two functional G-codes under one therapy plan of care (POC) Current status and goal status Discharge status and goal status May have more than two non-payable G- codes when patient receives therapy under more than one POC Same date of service and provider March

26 Claim Submission Reported as a separate line item Functional limitation data is comprised includes: Functional g-code Severity modifier Therapy modifier (GP,GO,GN) Do not report KX or 59 on these line items Non payable codes - $0.01 amounts March

27 Billing Claim Example HCPCS MODIFIER SERVICE DATE TOTAL UNITS TOTAL CHARGE GP G8978 GPCL GP G8979 GPCI No special sequencing of functional modifiers KX modifier and 59 modifier are not added to the functional G-code line item March

28 Required Functional Code Editing Common working File (CWF) tracks functional limitation based on Beneficiary information Therapy discipline reporting Billing Provider NPI To avoid returned or rejected claims submit claims in order by treatment date of service. March

29 Reporting Requirements Required at each progress reporting on or before the 10 th treatment day G-codes are always therapy codes Repeat adjusting severity modifier on the current G-code, when applicable Therapy modifiers are required GP under a PT POC GO under an OT POC GN under a SLP POC March

30 Reporting Requirements Beneficiary reaches the goal on first reported functional limitation; treatment continues for a second functional limitation using another set of G-codes Therapist may treat more than one functional level Only one can be reported at a time March

31 Reporting Requirements Q&A Do the G-Codes need to be reported on the same date the Progress Note was completed, or can they be independent of each other as long as both are within the once every 10th treatment day time period? The progress note written must include the G-codes and modifiers. It is required at every progress reporting period, which occurs at least once every 10 treatment days. March

32 Functional G-code Claim Reporting When to use G-codes and severity modifiers Starting therapy episode of care Evaluation of patient for possible future treatment Select a current and goal status g-code and modifier that best represents the limitation by percentage Cases of multiple functional limitations Choose one primary/priority treatment to report for the beneficiary March

33 One or More POC Same Discipline When two therapists of the same discipline (e.g. two physical therapists) treat a patient concurrently for different services, it is anticipated that one therapist will complete a single thorough initial patient evaluation. This will include an assessment for all of the medical conditions identified at the time of the evaluation. A Current status and Goal status non-payable functional reporting G-codes and severity modifiers will be required. March

34 One or More POC Different Conditions Under more than one POC for multiple disciplines (PT, OT and/or Speech Language Pathology (SLP)) include two G-codes for each discipline: Current Status and Goal Status or Goal Status and Discharge Status along with the severity modifiers During this episode of care one discipline may end, then include all three codes Current, goal and discharge status and modifier March

35 Functional G-Codes Pairs Code pairs must be selected from the same group at the outset of the therapy episode of care, including projected goal status, at specified points during treatment, and at the time of discharge Continued subsequent treatment select the set of G-codes to report the second functional limitation March

36 Functional G-Codes and Severity Modifiers Progress Reporting Period example Current Status and Goal Status G-codes remain the same (first monthly billing) Percentage of progress changed; severity modifier did not require adjustment at this time Rev Code Description HCPCS Serv. Date 430 OT- onset or evaluation G8987 GO CL (75%) OT G8988 GO CI (15%) OT progress 10 treatment G8987 GO CL (65%) OT G8988 GO CI (15%) March

37 Functional G-Codes Example Progress Reporting Period example Current Status and Goal Status G-codes remain the same (second monthly billing) Percentage of progress changed; severity modifier required adjustment at this time Projected goal severity modifier would not change unless the clinician adjust beneficiary s goal Rev Code Description HCPCS Serv. Date 430 OT progress 10 treatment G8987 GO CK (45%) OT G8988 GO CI (15%) March

38 Functional Discharge G-codes When to use g-codes and severity modifiers Discharge from therapy episode of skilled care Discharge at the end of one functional limitation Before reporting the subsequent functional limitation Patient discontinues treatment without notice March

39 Functional Limitation Q&A On a patient that self discharges and then returns for a different functional limitation BEFORE the 60 days, do you bill the discharge G-codes of the original functional limitation on the last date of service of the original functional limitation before they stopped coming to therapy? Yes. Once one functional limitation is discharged and further therapy is medically necessary reporting of the subsequent functional limitation begins on the next treatment DOS. March

40 Functional Limitation Q&A So to clarify...a clinician is to make an educated guess as to what the patient status is if they do not return for therapy? It does not seem right to assume their status if there is no way of knowing due to patient not returning for any follow-up care. Treatment encounter notes (sometimes referred to by clinicians as visit notes or progress notes ) describe each treatment session or individual patient visit. The last encounter note could be used to provide the G-code and modifier, if needed. March

41 Functional Reporting Discharge Without Notice Discharge - Patient discontinues without notice Goal Status G-code and severity modifier remain the same Discharge G-code and severity modifier would reflect the clinician s judgment Rev Code Description HCPCS Serv. Date Serv. Units Total Charges Noncovered Charges 430 OT G8988 GO CI OT G8989 GO CK March

42 Functional Reporting Discharge Skilled Care Ended Discharge from therapy episode of care Goal Status G-code and severity modifier remain the same Discharge G-code and severity modifier would reflect the beneficiary s functional status at the time of discharge Rev Code Description HCPCS Serv. Date Serv. Units Total Charges Noncovered Charges 430 OT G8988 GO CI OT G8989 GO CI March

43 Functional Reporting Discharge from First Limitation Discharge reporting for one functional limitation during an episode of care Goal Status G-code and severity modifier at last episode of care Discharge G-code and severity modifier would reflect the beneficiary s functional status at the time of progress reporting period March

44 Functional Reporting Documentation Requirements MBPM chapter 15 section 220.4

45 Who Documents Qualified PT, OT, SLP therapist furnishing the therapy services Provided incident to physician/npp Must meet incident requirements Physician/NPP personally furnishing the therapy services Qualified therapist furnishing services in CORF March

46 What is Documented Document on the applicable dates of service Specific non-payable G-code and severity modifier How the modifier was selected Examples of modifier selections used Single functional assessment tool Measurement instrument for severity modifier Clinical judgment for severity modifier March

47 Observation Services Observation is an outpatient service subject to functional reporting when therapy services are given G-codes and severity modifiers reflect patient functional impairment determined by clinician Consistent with evaluation, treatment and goals Append the functional therapy reporting codes March

48 Observation Services Does Functional Reporting apply to beneficiaries in observation status in the hospital? Yes. If the beneficiary s therapy 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. March

49 Lower Level of Care A patient in the Acute Hospital is downgraded to Intermediate Care Facility (ICF) level of care and there is PT/OT done during ICF days and we have to bill on a TOB 121, these claims Medicare denying because there is no functional G-codes, what should we do with these claims? The functional reporting requirements apply to Inpatient Part B; type of bill 12X. March

50 Where to Document Outset of the episode of care Evaluation, POC or treatment note End of each progress reporting period Document in the progress report Re-evaluation due to significant change in the patient s functional condition Document in the re-evaluation or treatment note March

51 Where to Document 2 Discharge from therapy episode or to end reporting one functional limitation before reporting a different limitation Document in the discharge note or summary Progress report related to the end of the functional limitation March

52 Where to Document 3 First treatment day after progress report that ended the previous functional limitation Document in the treatment note of the initial service at the time the reporting of a new functional limitation begins March

53 Documentation Requirements for Therapy CMS Internet Only Manual (IOM), Medicare Benefit Policy Manual, Publication , Chapter 15 section 220.3

54 Therapy Evaluations Initial and New evaluations Encompass all conditions when referred by one or more physicians New injury/unrelated condition New episode of care March

55 Additional Evaluative Services Re-evaluations, re-assessments, retesting Routine services of expected progression in accordance with the plan of care are not separately reimbursable as an evaluative service Completed by therapist March

56 Plan of Care Requirements Minimum required elements for plan of care: Diagnosis Type Amount/frequency/duration Long term goals March

57 Mandatory Certification Legible dated signatures Initial certification and Significantly modified Plans of Care Signature must be obtained within 30 days of the initial therapy treatment March

58 Recertification When is the recertification due? Duration on the initial plan of care OR 90 calendar days, whichever is less Recertification for services extending beyond the certified duration March

59 Progress Reports Interval reporting is mandatory Can be in a separate Progress Report Can be in Treatment Encounter Notes Required on or before every 10th treatment day Do not typically need to be reviewed or require a physician signature March

60 Progress Report Requirements Date of current Progress Note Date reporting began and ended Objective reports/measurements Assessment of improvement Plans for continued treatment Changes/updates to Plan of Care Legible Signature March

61 Medical Necessity Begins with Legible documentation Gather and document objective, measurable information and goals Document a clear picture of the patient s condition/abilities from before and with therapy Support why skilled therapy is necessary at this point in the patient s life Document progress in relation to the measurable goals March

62 Treatment Encounter Note Required for each visit Minimum elements include: Date of treatment Description of modality/intervention Total minutes of direct service Total minutes of time-based code services Legible signature and professional credentials of each person who contributed Can include the information required for the Progress Report March

63 Documentation Match Coding Documentation must support accurate billing: CPT/HCPCS code Number of units Occurrence codes March

64 Billing and Coding Guidelines

65 Claims Submission Identify Certifying Physician March

66 Reporting Requirements Evaluative Procedures Codes on claim for evaluation or revaluation require reporting functional G- codes and modifiers for the same date of service 92506, 92597, 92607, 92608, 92610, 92611,92612, 92614, 92616, 96105, 96125, 97001, 97002, and vices/annualtherapyupdate.html March

67 Institutional Claim Billing Billing Requirements Functional severity modifier range CH - CN Therapy modifier per discipline of POC DOS billable service Nominal charge Penny for institutional claims Must contain another billable and separately payable service March

68 Institutional Claim Billing 2 No special sequencing of functional modifiers KX modifier and 59 modifier are not added to the functional G-code line item Monetary amount for the non-payable G- codes is added to the total March

69 Billing One-time Therapy Visit Beneficiary is seen and future therapy services are Not medically indicated or Furnished by another provider Three G-codes are billed with severity modifiers to indicate Current status, goal status, and discharge status March

70 Physical Therapy Revenue Code 042x Modifier GP Service delivered personally by PT or under PT POC Occurrence Codes 11 Onset of symptoms/illness 29 Date PT plan established or last reviewed 35 Date PT treatment started March

71 Occupational Therapy Revenue Code 043x Modifier GO Service delivered personally by OT or under OT POC Occurrence Codes 11 Onset of symptoms/illness 17 Date OT plan established or last reviewed 44 Date treatment started for OT March

72 Speech Language Pathology Revenue Code 044x Modifier GN Service delivered personally by Speech Language Pathologist or under SLP POC Occurrence Codes 11 Onset of symptoms/illness 30 Date SLP plan established or last reviewed 45 Date treatment started for SLP March

73 Claims Processed CWF CWF will capture the amount when a service is billed with GN, GO, or GP modifier CWF will override and pay the MPFS allowed amount when greater than the financial limitation available At the claim line level Lines without KX modifier will be denied March

74 Medicare Secondary Payer (MSP) Medicare Secondary Payer MSPPAY will bypass non-payable G-codes with Q status indicator March

75 Remittance Advice (RA) and Medicare Summary Notice (MSN) Medicare Summary Notice 36.7 This code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount. Claim Adjustment Reason Code 246 This non-payable code is for required reporting only. March

76 Resources Medicare Claim Processing Manual, Internet Only Manual (IOM) Chapter 5, Section Guidance/Guidance/Manuals/Downloads/c lm104c05.pdf March

77 Resources Medicare Claims Processing Manual, IOM Chapter 5, Section Guidance/Guidance/Manuals/Downloads/clm 104c05.pdf Medicare Benefit Policy Manual, IOM Chapter 15, Section Guidance/Guidance/Manuals/Downloads/bp1 02c15.pdf March

78 Resources 2 Functional Reporting Quick Reference Chart Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/G-Codes-Chart pdf MLN Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM9448.pd f March

79 Resources 3 Functional Reporting ices/functional-reporting.html CR Guidance/Guidance/Transmittals/Downloads/R11 96OTN.pdf SE Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1307.pdf March

80 What questions do you have? Thank you.