Outpatient Therapy G-Code Edit Findings January 30, Mary Sue Gardner, RN/BSN Senior Nurse Analyst

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1 Outpatient Therapy G-Cde Edit Findings January 30, 2014 Mary Sue Gardner, RN/BSN Senir Nurse Analyst Backgrund Sectin 3005(g) f the Middle Class Tax Relief and Jbs Creatin Act (MCTRJCA) amended Sectin 1833(g) f the Scial Security Act t require a claims-based data cllectin system fr utpatient therapy services, including physical therapy, ccupatinal therapy and speech-language pathlgy services. The system will cllect data n beneficiary functin during the curse f therapy services in rder t better understand beneficiary cnditins, utcmes, and expenditures. This data will be used in develping an imprved payment system. Agenda Backgrund infrmatin n the G-cde regulatins Edit findings Applicatin f New Cde Requirements Effective fr therapy services with dates f service, n r after January 1, 2013 Testing perid: January 1, June 30, 2013 Required cmpliance July 1, 2013 New status indicatr f Q created fr Medicare Physician Fee Schedule Database (MPFSDB) Infrmatinal cde, reprting purpses nly Services Affected Applies t all claims fr services furnished under the Medicare Part B utpatient therapy benefit Applies t services furnished persnally by and incident t service f a physician r Nn physician Practitiner (NPP); Nurse Practitiner (NP), Certified Nurse Specialist (CNS), and Physician Assistant (PA) Prviders Hspitals Critical Access Hspitals (CAH) Skilled Nursing Facilities (SNF) Prviders and Practitiners Affected Cmprehensive Outpatient Rehabilitatin Facilities (CORF) Created 12/04/

2 Rehabilitatin agencies Hme Health (HH) agencies When beneficiary is nt under HH plan f care Prfessinals Therapists in private practice Physical Therapist (PT), Occupatinal Therapist (OT), Speech Language Pathlgist (SLP) Physicians Dctr f Medicine (MD), Dctr f Ostepathy (DO), Dctrs f Pdiatric Medicine (DPM) and Dctr f Optmetry (OD) NPPs (NP, CNS, PA) G-cdes are Always Therapy cdes Functin Related G-cde Sets Require a therapy mdifier: GP - under a PT Plan f Care (POC) GO - under and OT POC GN - under an SLP POC Each functinal G-cde set cntains: Current status Prjected gal status Discharge status There are 42 functinal G-cdes, 14 sets f 3 cdes Generally, 6 f the G-cde sets are used fr PT and OT functinal limitatins and 8 fr SLP Severity/Cmplexity Mdifiers Each G-cde must have 1 severity/cmplexity mdifier which reflects a percentage f functinal impairment as determined by the therapist, physician r NPP furnishing the service Mdifier CH CI CJ CK CL CM CN Impairment Limitatin Restrictin 0 percent impaired, limited r restricted At least 1 percent but less than 20 percent impaired, limited r restricted At least 20 percent but less than 40 percent impaired, limited r restricted At least 40 percent but less than 60 percent impaired, limited r restricted At least 60 percent but less than 80 percent impaired, limited r restricted At least 80 percent but less than 100 percent impaired, limited r restricted 100 percent impaired, limited r restricted This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 2 f 9

3 Required Reprting f Functinal G-cdes and Severity Mdifiers Used in required reprting fr certain dates f service At the utset f a therapy episde f care (date f service (DOS) fr initial therapy services) At least nce every 10 treatment days (n r befre the 10 th treatment day, which matches new prgress reprting effective January 1, 2013) When evaluatin r re-evaluatin is furnished and billed At time f discharge frm therapy episde f care On the same DOS the reprting f a particular functinal limitatin is ended, in cases where there is need fr further therapy At the time reprting is begun n a different (secnd, third) functinal limitatin within the same episde f care Only 1 functinal limitatin shall be reprted at a given time fr each related therapy POC Functinal reprting is required n claims thrughut the entire episde f care Under ne therapy plan f care the minimum number f functinal G-cdes required n a claim will be tw Current status and gal status Discharge status and gal status Tw exceptins exist t the number f functinal G-cdes required n a claim Therapy services under mre than ne therapy POC PT, OT and/r SLP frm same therapy prvider One-time therapy visit Further therapy services nt medically indicated Further therapy services will be furnished by anther prvider Reprt all 3 G-cdes in the apprpriate cde set (current status, gal status and discharge status) alng with crrespnding severity mdifiers Each reprted functinal G-cde must als cntain the fllwing essential line f service infrmatin Functinal severity mdifier Therapy mdifier indicating the related discipline/poc (GP, GO r GN) Date f service Nminal charge A penny fr institutinal claims submitted t Part A Zer charge fr prfessinal claims t Part B If billing sftware requires an amunt fr prfessinal claims, a penny may be included This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 3 f 9

4 Claims cntaining any f these functinal G-cdes must als cntain anther billable and separately payable (nn-bundled) service The KX and 59 mdifiers are nt applicable t the line f service fr the functinal G-cdes Edit Findings Recent denial reprts shw increasing errrs with Therapy Functinal Reprting G-cdes. The fllwing reasn cdes cntain examples f the mst cmmn errrs. Reasn Cde: E6104 The current and gal OR gal and discharge functinal G-cdes are nt apprpriately paired frm the same functinal G-cde set. The claim must have functinal G-cdes frm the same functinal grup set. Example #1: Current Status: Mbility Current (G8978) Discharge Status: Mbility Discharge (G8980) N Gal Status listed Examples #2: 10/2/13: Self-Care Current (G8987) Self-Care Gal (G8988) 10/30/13: Mbility Current (G8978) Self-Care Gal (G8988) Reasn Cde: U5452 The therapy claim has a different functinal G-cde set than the psted reprting episde which has nt been discharged and has the same billing prvider Natinal Prvider Identifier (NPI) and same discipline. Example #1: PT 42X 10/1/13 Other PT/OT Current (G8990) CMGP Other PT/OT Gal (G8991) CKGP PT 42X 10/14/13 Other PT/OT Gal (G8991) CKGP Other PT/OT Discharge (G8992) CLGP OT 43X 10/1/13 Self-Care Current (G8987) CJGP This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 4 f 9

5 Self-Care Gal (G8988) CIGP The incrrect therapy mdifier was appended, making the G-cdes appear as if the patient was admitted t Other PT/OT and Self Care n the same date. Example # 2: OT 43X 10/29/13 Bdy Psitin Gal (G8982) Bdy Psitin Discharge (G8983) Self-Care Current (G8987) Self-Care Gal (G8988) Cannt reprt discharge frm 1 G-cde set and start f new G-cde set n the same date f service. Reasn Cde Evaluatin/Re-evaluatin cdes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, r nt submitted with Current Status and Gal Status plus severity mdifiers OR evaluatin cdes nt submitted with apprpriately paired G- cdes/severity mdifiers. Example # 1: SLP 44X 10/2/13 Dysphagia Evaluatin, Treatment (92611) Swallwing Current (89996) Swallwing Discharge (G8998) Therapy evaluatin cde with G-cdes that are nt apprpriately paired (Current and Gal) Reasn Cde U5453 Claims with paired gal/discharge G-cdes were received ut f sequence and there is an pen r discharged reprting perid in the histry. Example #1: Claim dates 10/23/13 10/30/13 received and prcessed prir t the 10/02/13 10/21/136 dates f service The 10/23/13 10/30/13 claim cntained new therapy evaluatin and new G-cdes with a new current status and gal status Since the dates f service f 10/02/13 10/21/13 were received and prcessed after 10/23 10/30 the system did nt recgnize that the prir reprted G-cdes cntained a reprted discharge Reasn Cde U5451 The 10 th therapy service with dates f service n r after 10/01/13 is missing: Current Status and Gal Status/severity mdifiers OR Gal Status and Discharge Status/severity mdifiers Edit Issue This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 5 f 9

6 Mass adjustment n the claims is currently in place Edit being wrked Claims shuld n lnger reject fr this edit until further ntice Reasn Cde U5450 The initial therapy service with dates f service n r after 10/1/13 must be billed with the functinal current status G-cde/severity mdifier and paired functinal gal status G- cde/severity mdifier. (Services after 10/1/13 with an initial evaluatin r re-evaluatin, must als cntain current status and gal status G-cdes) Reasn Cde U5454 There is an pen reprting perid, fr the same discipline, and the incming claim has a FROM date that is 60 r mre calendar days since the last THRU date. Example # 1 Claims that prcess ut f sequence will hit the system edit as it may nt appear that a specific G-cde was discharged prir t admitting t a new G-cde set. Example # 2 Claims that d nt cntain a discharge frm a prir reprted G-cde set (patient selfdischarges and n G-cdes are reprted) and then the patient returns t the same therapy prvider, same NPI fr the same discipline f service. Claims will hit the edit because there is a prir pen reprting perid fr the same NPI, same prvider in the same discipline. Summary f G-cde Findings If a therapy evaluatin r re-evaluatin is billed, G-cdes/severity mdifiers must be reprted n the same day (Current Status and Gal Status r Gal and Discharge) A minimum f 2 G-cdes frm 1 G-cde set must be reprted at each required reprting interval Current and Gal Gal and Discharge Only reprt all 3 fr ne time treatment visits The G-cdes must be reprted at least every 10 treatment days Claims that prcess ut f sequence may cause a claim t hit a G-cde edit and require subsequent bills t be cancelled and then rebilled in sequence Be sure t reprt the severity mdifier as well as the prper therapy mdifier with the G-cdes PT= GP OT = GO SLP = GN When changing frm ne G-cde set t anther, prviders cannt reprt bth sets n the same date f service. The first G-cde set wuld be billed with gal status and discharge status n the day the This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 6 f 9

7 therapist determines the need fr the change and n the very next treatment day the prvider wuld reprt the current status and gal status f the next G-cde set. G-cdes must be apprpriately paired frm the same G-cde set Prviders are encuraged t clse a reprted G-cde set (gal status and discharge status), even if a patient self-discharges frm therapy services. This will help t avid future edits if that patient returns fr the same discipline f service frm the same prvider References 42 CFR , 60 and 62 ( vl2-sec410-59/cntent-detail.html) Medicare Internet-Only Manual (IOM), Publicatin , Claims Prcessing Manual, Chapter 5 ( Sectin 10.6 Change Request 8005 ( Guidance/Guidance/Transmittals/Dwnlads/R2622CP.pdf), Transmittals 2622 and 165, December 21, 2012 MLN Matters, MM8005 ( MLN/MLNMattersArticles/Dwnlads/MM8005.pdf), Related CR Transmittal #R2603CP, Effective January 1, 2013, Implementatin Date: January 7, 2013 MLN Matters, MM8126 ( MLN/MLNMattersArticles/Dwnlads/MM8005.pdf), Related CR Transmittal #R2596CP, Effective January 1, 2013, Implementatin Date: January 7, 2013 This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 7 f 9

8 Addenda t the January 30, 2014 Call with Q&A Q. Hw d I reprt an evaluative prcedure when it is fr a different functinal limitatin than I am currently reprting? A. Yu shuld reprt the evaluative prcedure furnished fr a secnd/different functinal limitatin ther than the primary functinal limitatin fr which nging reprting is ccurring as a ne-time visit (i.e., reprt all three (3) G-cdes in the cde set fr the functinal limitatin that mst clsely matches that fr which the evaluative prcedure was furnished). The nging reprting f a primary functinal limitatin is nt affected when all three (3) G-cdes in a cde set are reprted fr the evaluative prcedure fr a secnd functinal limitatin. Nte: The reprting f all 3 G-cdes fr the evaluative prcedure fr a secnd functinal limitatin and the nging reprting f a primary functinal limitatin CAN bth ccur n the same date f service. Q. Hw d I reprt functinal infrmatin when the beneficiary has tw plans f care frm tw different physicians fr separate cnditins? A. Assuming the same prvider submits the claim fr services under bth POCs, nly ne functinal limitatin can be reprted at a time per discipline. Yu will need t decide upn which POC Functinal Reprting will ccur. Treatment days fr bth cnditins are cunted twards the reprting frequency cunting each treatment day twards the ttal number f days the beneficiary received services, under bth POCs. Nte: It cunts as ne treatment day when services are received n the same date f service under bth POCs. Q. If the patient self-discharges frm therapy, hw d we reprt G-cdes? A. There are several ptins the prvider can take when a patient self-discharges: 1. If a patient self-discharges prir t the bill being submitted t Medicare, the prvider can append the Gal and Discharge G-cdes/mdifiers t the last billable date f service, if the therapist has a reasnable estimate f their prgress. 2. In the event that the patient self-discharges and the facility has already submitted the last bill t Medicare, prviders wuld nt have t supply the discharge G-cdes if the therapist did nt have a reasnable estimate f the patient s prgress. 3. If the patient self-discharges and n discharge G-cdes/mdifiers were reprted, then the episde f care will remain pen fr 60 days. If the patient returns t the same therapy prvider (same prvider number, same facility NPI) prir t 60 days, the facility will need t discharge frm the prir reprted G-cde set befre reprting a new G-cde set. (Reprt the Gal and Discharge f the prir reprted G-cde set n the evaluatin day. On the very next treatment day, reprt the Current and Gal f the new G-cde set.) If the G-cde set will remain the same, the prvider can cntinue reprting the Current Status and Gal Status (frm the prir reprted G-cde set) at the time f the evaluatin. If the patient des nt return within 60 days, the system will autmatically end the episde f care. 4. Prviders cannt submit G-cdes withut anther billable service n the claim. S the Gal and Discharge Status/mdifiers either have t be appended t the last treatment day, r left as nt reprted. The prvider always has the ptin f adjusting the last bill t Medicare and adding the Gal and Discharge t the last date f service. This wuld be dependent n if the therapist had a reasnable estimate f the patient's prgress, and the facility s internal plicy t adjust prir submitted claims. This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 8 f 9

9 Q. Des it make a difference which mdifier initially fllws the functinal G-cde: severity/cmplexity r therapy mdifier when billing? A. N. The therapy mdifier and the severity mdifier may be reprted in any rder. Q. When we cunt the 10 treatment visits, des the evaluatin cunt as day ne r is it the next treatment visit after the evaluatin day ne in the cunting series? A. The minimum prgress reprt perid shall be at least nce every 10 treatment days. The day beginning the first reprting perid is the first day f the episde f treatment regardless f whether the service prvided n that day is an evaluatin, re-evaluatin r treatment. Regardless f the date n which the reprt is actually written (and dated), the end f the prgress reprt perid is either a date chsen by the clinician r the 10th treatment day, whichever is shrter. The next treatment day begins the next reprting perid. The prgress reprt perid requirements are cmplete when bth the elements f the prgress reprt and the clinician s active participatin in treatment have been dcumented. Fr example, fr a patient evaluated n Mnday, Octber 1, and being treated five times a week, n weekdays: On Octber 5, (befre it is required), the clinician may chse t write a prgress reprt fr the last week s treatment (frm Octber 1 t Octber 5). Octber 5 ends the reprting perid and the next treatment n Mnday, Octber 8, begins the next reprting perid. If the clinician des nt chse t write a reprt fr the next week, the next reprt is required t cver Octber 8 thrugh Octber 19, which wuld be 10 treatment days. CMS Functinal Reprting: PT, OT and SLP Services Frequently Asked Questins (FAQs) ( OT-SLP-Services-FAQ.pdf) This prgram is presented fr infrmatinal purpses nly. Current Medicare regulatins will always prevail. Page 9 f 9