New Functional Limitation Reporting Requirements Under Medicare Part B

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1 New Functional Limitation Reporting Requirements Under Medicare Part B Heather Smith, PT, MPH 1 BACKGROUND AND OVERVIEW 2 1

2 History of Medicare Therapy Caps and Reform Payment in Therapy Services BBA Therapy cap Call for reformed therapy payment 2006 MEI TRHCA 2007 MMSEA 2008 MIPPA 2010 PPACA 2011 TPTCCA 2012 MCTRJCA Mandated CMS to collect functional data on beneficiaries Functional Limitation Reporting Implementation 3 Functional Limitation Reporting Background Middle Class Tax Relief Act of 2012 CMS was mandated to collect information regarding the beneficiaries on the claim form: Function and condition Therapy services furnished Outcomes achieved on patient function CMS intends to utilize this information in the future to reform payment for outpatient therapy services 4 2

3 Program Basics: Who All practice settings that provide outpatient therapy services: PT, OT, and SLP services furnished in hospitals critical access hospitals skilled nursing facilities CORFs rehabilitation agencies home health agencies private offices of therapists, physicians and non physician practitioners 5 Program Basics: What Therapy service providers will submit nonpayable G codes with severity modifiers on their claims for the current status and projected goal Functional limitation categories include: Mobility: walking and moving around Changing and maintaining body position Carrying, moving and handling objects Self care Other Discipline Specific Category Codes Other Codes PT 4 2 OT 4 2 SLP 7 1 shared 6 3

4 Program Basics: When Functional limitation G codes will be submitted for the primary limitation: At the outset of the therapy episode At a minimum every 10 th visit At a formal re evaluation At discharge/ end reporting (unless the patient self discharges prior to formal discharge visit) A subsequent functional limitation may be reported if care continues to address the subsequent limitation after you end reporting of the primary limitation 7 Program Basics: How Therapists will use a valid and reliable assessment tool(s) and/or objective measure(s) in determination of the severity of the functional limitation Multiple tools may be used Therapist judgment may be used in the severity modifier determination in combination with data gathered Documentation of the G codes and the rationale for selection of severity must be included in the medical record 8 4

5 Reporting Timeline January 1 June 30, month testing period for functional limitation data submission July 1 December 31, 2013 Claims will be returned unpaid if functional information is missing 9 REPORTING DETAILS 10 5

6 Nonpayable G codes G codes are based on the International Classification of Functioning, Disability and Health (ICF) Functional limitation: activity limitations + participation restriction Specific categories plus an other category Therapist chooses the most appropriate category: Most clinically relevant to a successful outcome for the beneficiary; The one that would yield the quickest and/or greatest functional progress; OR The one that is the greatest priority for the beneficiary 11 Nonpayable G codes Choosing Other Defined by one of the four specific categories Therapy services are not intended to treat a functional limitation When an overall, composite or other score from a functional assessment tool (such as FOTO, etc.) is used and it does not clearly represent a functional limitation defined by one of the four code sets. Other PT/OT Subsequent Functional Limitation category is only selected after the Other PT/OT Primary Functional Limitation category has been reported on the beneficiary during the same episode of care. 12 6

7 Nonpayable G codes Guide Code Information Communicated When Reported GXXX Current functional status Therapy episode outset (initial evaluation) Reporting intervals (every 10 th visit) Formal re evaluation (if performed during the episode) GXXX Projected goal functional status Therapy episode outset (initial evaluation) Reporting intervals (every 10 th visit) Formal re evaluation (if performed during the episode) Discharge from therapy OR to end reporting GXXX Discharge functional status Discharge from therapy OR to end reporting 13 Nonpayable G codes CY2013 Mobility: Walking & Moving Around G8978 G8979 G8980 G8981 G8982 G8983 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Changing & Maintaining Body Position Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting 14 7

8 Nonpayable G codes CY2013 Carrying, Moving & Handling Objects G8984 G8985 G8986 G8987 G8988 G8989 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Self Care Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care functional limitation, discharge status, at discharge from therapy or to end reporting 15 Nonpayable G codes CY2013 Other PT/OT Primary Functional Limitation G8990 G8991 G8992 G8993 G8994 G8995 Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting Other PT/ OT Subsequent Functional Limitation Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting 16 8

9 Severity Modifiers 7 point scale Choosing the modifier: Reflects the score from a functional assessment tool or other performance measurement instrument. Combine the results of multiple measurement tools used during the evaluative process Clinical judgment in the assignment of the appropriate modifier. CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation 17 Severity Modifiers CY2013 Modifier Impairment Limitation Restriction CH CI CJ CK CL CM CN 0 percent impaired, limited or restricted At least 1 percent but less than 20 percent impaired, limited or restricted At least 20 percent but less than 40 percent impaired, limited or restricted At least 40 percent but less than 60 percent impaired, limited or restricted At least 60 percent but less than 80 percent impaired, limited or restricted At least 80 percent but less than 100 percent impaired, limited or restricted 100 percent impaired, limited or restricted 18 9

10 Reporting Frequency G codes are reported throughout care at specific intervals Report only on one limitation (primary) You may report on a second limitation but not simultaneously If a patient is seen for a second condition beyond the resolution of first then you will report a second (subsequent) limitation 19 Reporting Frequency Submission of 2 G codes at each reporting interval except: Therapy services under more than one therapy POC 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 current status, goal status and discharge status on the claim 20 10

11 Functional Limitation Reporting Outset (Primary Limitation) Current functional status Projected functional goal Re Evaluation Current functional status Projected functional goal Every 10 th Visit Current functional status Projected functional goal Discharge Discharge functional status Projected functional goal End of Reporting (Primary Limitation) Discharge functional status Projected functional goal Reporting of Subsequent Current functional status Projected functional goal Reporting of Subsequent Follow reporting requirements for primary 21 Example of Required Reporting Evaluation/ Beginning of reporting period #1 Visits #2 9 Mobility: Walking & Moving Around G8978 Current X G8979 Goal X G8980 Discharge G8990 Current Other Primary G8991 Goal G8992 Discharge No Reporting No code submitted X End of reporting period #1 (10 th visit) X X Reporting period #2 begins (11 th visit) X Visits #12 13 X Visit #14/ End of reporting on Walking & Moving X X Begin Reporting Period for other primary (15 th visit) Visits #16 19 X X X 22 End of reporting period #2 (20 th visit)/ Discharge X X 11

12 Claim Submission Functional limitation data is comprised of three pieces of information: G code Severity modifier Therapy modifier No required order for the modifiers No KX modifier Reported as a separate line item Nonpayable code $0.01 or $ Submission Acknowledgement Medicare will return a Claim Adjustment Reason Code 246 (This non payable code is for required reporting only.) and a Group Code of CO (Contractual Obligation) assigning financial liability to the provider. In addition, beneficiaries will be informed via Medicare Summary Notice 36.7 that they are not responsible for any charge amount associated with one of these G codes

13 Claim Form Example 1500 Functional limitation data with Therapy modifier and severity modifier (GP & CL/CI) Do not use the KX modifier PQRS Quality Data Codes (QDC s) Both functional limitation and PQRS G codes are submitted with either $0.00 or $0.01 charge 25 Both functional limitation and PQRS G codes are submitted with either blank unit section or 1 unit attached Claims Example: UB 04 Functional limitation data with Therapy modifier and severity modifier (GP & CL/CI) Do not use the KX modifier Functional limitation G codes should be submitted with either $0.00 or $0.01 charge Functional limitation G codes are submitted with either blank unit section or 1 unit attached 26 13

14 PQRS vs Functional Limitation Reporting Program Detail Program start date Participants (Medicare Part B) Reporting method Reporting frequency Information reported PQRS 2007 (incentive program) 2015 (penalty program) Eligible professionals (including PT, OT, SLP) billing for outpatient physical therapy services in private practice settings Facility based outpatient practices are not able to participate Claims Registry EHR Determined by CPT codes submitted (97001, 97002, several wound care codes) Quality Data Code (QDC) G code QDC modifier (1P, 8P) Functional Limitation Reporting January 1, 2013 July 1, 2013 (non payment) All practice settings that provide outpatient therapy services (PT, OT, and SLP) furnished in all outpatient settings including facilities Claims Determined by visit (evaluation, every 10 th, re evaluation, discharge) Functional limitation G code Therapy modifier Severity modifier 27 CASE SCENARIOS 28 14

15 Functional Data Requirements Determine primary functional limitation Select an appropriate functional assessment tool(s) or objective measure(s) Determine the category of the primary functional limitation Determine the severity of limitation Determine the projected goal Based on the current functional limitation status and other patient information Determine the projected goal Report the functional limitation data Current/ discharge status with severity modifier Projected goal with severity modifier 29 Scenario for Patient with LBP 65 y/o male 3 days s/p onset of acute low back pain (LBP) with (L) LE pain into posterior thigh to knee Second episode of this condition in the past 6 mo. Previous episode had no LE symptoms. Injury is not work related Comorbidities include hypertension controlled by medication Patient works for painting contractor. Has been on bed rest since onset 30 15

16 Determine Current Functional Status The physical therapist chooses the Oswestry Disability Index for LBP to measure the functional limitation status for this patient. The Oswestry has 10 sections covering areas from pain to employment. It includes questions for activity limitations and participation restrictions from ICF on which the G codes are based. 31 Initial Evaluation Functional Measurement Data Oswestry Disability Index Test Key findings Score Severity translation 35 35% impaired; At least 20 but less than 40% impaired, limited or restricted CJ modifier Functional limitation category Mobility: walking & moving around G8978 CJ 32 16

17 Determine Projected Goal Patient reports that his primary goal for PT is to return to work and prior function. He also wants to have the skills to prevent reoccurrence. They agreed upon a goal to return to prior function. The PT then has a goal of 0 on the Oswestry (CH modifier). G8979 CH 33 Initial Evaluation Functional Limitation Documentation Patient reports that his primary goal for PT is to return to work and prior function (G8978) with minimal help. His current impairment level is 20 to 40 percent impaired (CJ) based on his Oswestry score. He is expected to be achieve a score of 0 percent impaired (G8978 CH) after 12 therapy visits

18 Example of Charge form for Initial Evaluation visit th Visit Description The patient had been doing well and his Oswestry score had gone down to 11 his last visit. However, he went on a 6 hour car trip over the weekend and due to the weather he did not get out on a regular basis to perform his extension exercises. He reports he now again has occasional pain down his thigh. The patient s Oswestry Score is 42 today

19 10 th Visit Functional Measurement Data Oswestry Disability Index Test Key findings Score Severity translation 42 42% impaired; At least 40 but less than 60% impaired, limited or restricted CK modifier Functional limitation category Mobility: walking & moving around G8978 CK th Visit Documentation Patient reports that his primary goal for PT is to return to work and prior function (G8978) with minimal help. His current impairment level is 40 to 60 percent impaired (CK) based on his Oswestry score of 42. He is still expected to be achieve a score of 0 percent impaired (G8979 CH) after 12 therapy visits

20 Example of Charge Form for 10 th Visit 39 Discharge Visit Description Visit 12 Patient returns after 2 weeks for review and progression of his home exercise program and fitness program. He reports he has been performing his exercises and positioning routinely. He is symptom free and has returned to work without difficulty. The patient has reached the projected functional goal

21 Discharge Visit Functional Measurement Data Oswestry Disability Index Test Key findings Score Severity translation 0 0% impaired, limited or restricted CH modifier Functional limitation category Mobility: walking & moving around G8980 CH 41 Discharge Visit Documentation Patient reports that he has returned to work and his prior level of function (G8980). His current impairment level is 0 percent impaired (CH) based on his Oswestry score of 0. He has achieved his therapy goals and is 0 percent impaired (G8979 CH) at discharge

22 Example of Charge Form for Discharge Visit 43 Summary of Reporting Initial Evaluation Visit 10 th Visit D/C Visit G code Modifier G code Modifier G code Modifier G8978 CJ G8978 CK G8979 CH G8979 CH G8980 CH G8979 CH Mobility: Walking & Moving Around Mobility: walking & moving around functional limitation, G8978 current status, at therapy episode outset and at reporting intervals G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Modifier Impairment Limitation Restriction CH 0 percent impaired, limited or restricted CI CJ CK CL CM CN At least 1 percent but less than 20 percent impaired, limited or restricted At least 20 percent but less than 40 percent impaired, limited or restricted At least 40 percent but less than 60 percent impaired, limited or restricted At least 60 percent but less than 80 percent impaired, limited or restricted At least 80 percent but less than 100 percent impaired, limited or restricted 100 percent impaired, limited or restricted 44 22

23 Scenario for Patient s/p CVA 83 y/o female four week s/p ischemic event of the left middle cerebral artery resulting in right hemiplegic and mild aphasia Previous therapy includes inpatient rehabilitation Co morbidity of severe osteoporosis with wrist, hip, and spinal compression fractures within past year Chief complaints include assistance needed to walk short distance and weakness or right arm Reports fatigue with minimal exertion 45 Determine Current Functional Status PT Tests and Measures: OPTIMAL Berg balance test 4meter walk OT Tests and Measures: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire 46 23

24 Initial Evaluation Functional Measurement Data OPTIMAL Test Key findings Score Severity translation Patient identified: walking outdoors* climbing up stairs carrying objects Berg balance test 4 meter walk Walks with close supervision and use of cane 9 (on primary item*) 29/56 70 percent limitation: At least 60 but less than 80% impaired, limited or restricted CL modifier Functional limitation category Mobility: walking & moving around G8978 CL 4 meter walk at 0.6 m/sec 47 Initial Evaluation Functional Measurement Data DASH Test Key findings Score Severity translation Identified issues with ADL s percent limited: 40 percent limitation: At least 40 but less than 60 %impaired, limited or restricted CK modifier Functional limitation category Self Care: G8987 CK 48 24

25 Determine the Projected Goal Physical Therapy Prior to CVA lived in home w husband and was independent in ADLs and driving Goal is to return to this setting and prior activities Projected goal is at least 1 percent but less than 20 percent impaired, limited or restricted (CI modifier) G8979 CI Occupational Therapy Prior to CVA lived in home w husband and was independent in ADLs and driving Goal is to return to this setting and prior activities Projected goal is at least 1 percent but less than 20 percent impaired, limited or restricted (CI modifier) G8988 CI 49 Initial Evaluation Functional Limitation Documentation Physical Therapy Patient s primary goal for PT is to be able to walk outdoors with minimal help. Her current impairment level is 70% (G8978 CL) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She is expected to be able to walk outside her home with less than 20% (G8979 CI) impairment after 8 weeks of therapy. Occupational Therapy Patient s primary goal for OT is to be able to perform ADL s with minimal help. Her current impairment level is 54% (G8987 CK) based on her DASH score. She is expected to be able to perform her ADL s with less than 20% (G8988 CI) impairment after 8 weeks of therapy

26 Example of Charge Form for Initial Evaluation Visit th Visit Description The patient is happy with her progress She is able to walk with only close supervision now demonstrating slightly greater walking speed She still notes some decreased confidence walking outside Her balance is improved especially with single limb stance activities Her arm function has also improved and she is able to dress with minimal difficulty and perform ADL s more easily 52 26

27 10 th Visit Functional Measurement Data OPTIMAL Test Key findings Score Severity translation Patient identified: walking outdoors* climbing up stairs carrying objects Berg balance test 4 meter walk Walks with close supervision without an assistive devise 5 (on primary item*) 40/56 40 percent limitation: At least 40 but less than 60 %impaired, limited or restricted CK modifier Functional limitation category Mobility: walking & moving around G8978 CK 4 meter walk at 0.8 m/sec th Visit Functional Measurement Data DASH Test Key findings Score Severity translation Some issues with ADL s percent limited: 40 percent limitation: At least 20 but less than 40 %impaired, limited or restricted CJ modifier Functional limitation category Self Care: G8987 CJ 54 27

28 10 th Visit Documentation Physical Therapy Patient has improved in safety with her mobility. Her current impairment level for walking around (G8978) is 40% (CK) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She is expected to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy. Occupational Therapy Patient is better able to perform her ADL s. Her current impairment level for ADL s is 32% (G8987 CJ) based on her DASH score. She is expected to be able to perform her ADL s with less than 20% (G8988 CI) impairment at time of discharge from occupational therapy. 55 Example of Charge Form for 10 th Visit 56 28

29 Discharge Visit Description Visit 12 The patient is much more confident moving around outside She is able to walk independently at a speed that is appropriate for community participation Her balance is improved overall and her Berg score indicates she has a low fall risk She is able to dress independently and perform other ADL s with minimal difficulty 57 Discharge Visit Functional Measurement Data OPTIMAL Test Key findings Score Severity translation Patient identified: walking outdoors* climbing up stairs carrying objects Berg balance test 4 meter walk Walks independently without an assistive devise 3 (on primary item*) 46/56 10 percent limitation: At least 1 but less than 20 %impaired, limited or restricted CI modifier Functional limitation category Mobility: walking & moving around G8980 CI 4 meter walk at 1.0 m/sec 58 29

30 Discharge Visit Functional Measurement Data DASH Test Key findings Score Severity translation Mild issues with ADL s percent limited: 10 percent limitation: At least 1 but less than 20 %impaired, limited or restricted CI modifier Functional limitation category Self Care: G8989 CI 59 Discharge Visit Documentation Physical Therapy Patient has improved in safety with her mobility. Her current impairment level for walking around (G8980) is 10% (CI) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She has achieved her goal to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy. Occupational Therapy Patient able to perform her ADL s with minimal difficulty. Her current impairment level for ADL s is 16% (G8989 CI) based on her DASH score. She has achieved her goal to perform her ADL s with less than 20% (G8988 CI) impairment and is discharged from occupational therapy

31 Example of Charge Form for Discharge visit 61 Summary of reporting Provider Initial Evaluation Visit 10 th Visit D/C Visit G code Modifier G code Modifier G code Modifier PT G8978 CL GP G8978 CK GP PT G8979 CI GP G8979 CI GP G8979 CI GP PT G8980 CI GP OT G8987 CK GO G8987 CK GO OT G8988 CI GO G8988 CI GO G8988 CI GO OT G8989 CI GO Mobility: Walking & Moving Around Mobility: walking & moving around functional limitation, current status, G8978 at therapy episode outset and at reporting intervals G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Self Care Self care functional limitation, current status, at therapy G8987 episode outset and at reporting intervals G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting Modifier Impairment Limitation Restriction CH 0 percent impaired, limited or restricted CI CJ CK CL CM CN At least 1 percent but less than 20 percent impaired, limited or restricted At least 20 percent but less than 40 percent impaired, limited or restricted At least 40 percent but less than 60 percent impaired, limited or restricted At least 60 percent but less than 80 percent impaired, limited or restricted At least 80 percent but less than 100 percent impaired, limited or restricted 100 percent impaired, limited or restricted 62 31

32 Resources APTA website allimitation/ Basic program information/ FAQ Discussion forum Case studies Webinar CMS website ml 63 Questions 64 32

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