MEDICARE G-CODES. Implementation of the Claims Based Data Collection on Therapy Services. Rhonda Reininger, M.A., O.T.R, C.H.T.

Transcription

1 MEDICARE G-CODES Implementation of the Claims Based Data Collection on Therapy Services Rhonda Reininger, M.A., O.T.R, C.H.T. Rehab Compliance

2 WHY? Required by the Middle Class Tax and Relief and Job Creation Act of 2012 CMS was required to implement beginning on January 1, 2013 a claims based data collection strategy designed to assist in reforming the Medicare payment system for outpatient therapy services The goal is to provide data on patient function during the course of therapy services in order to better understand patient condition and outcomes.

3 WHEN? Testing Period: G-Codes & Modifiers are being accepted on claims. Mandatory Reporting: Therapy claims that do not comply with reporting requirements will be denied.

4 HOW? Non-payable G-codes and severity modifiers will be used to provide information about the patient s functional status They will be used: o Outset of therapy episode of care (IE) o Specified points during treatment (at a minimum every 10 visits) o Discharge o When an eval or re-eval is billed o To end reporting of one functional limitation o To begin reporting of a different functional limitation

5 G-CODES There are 14 areas of functional limitation defined. Within each area, there are three G-codes. One for current status, one for projected goal status, one for discharge status Total = 42 new G-codes

6 EXAMPLE Mobility: Walking & Moving Around G8978 Mobility current status G8979 Mobility goal status G8980 Mobility D/C status

7 THERAPY FUNCTIONAL REPORTING G-CODES (SHORT DESCRIPTORS) Mobility: Walking & Moving Around G8978 Mobility current status G8979 Mobility goal status G8980 Mobility D/C status Changing & Maintaining Body Position G8981 Body pos current status G8982 Body pos goal status G8983 Body pos D/C status Carrying, Moving and Handling Objects G8984 Carry current status G8985 Carry goal status G8986 Carry D/C status Self-Care G8987 Self-care current status G8988 Self-care goal status G8989 Self-care D/C status Other PT/OT Primary G8990 Other PT/OT current status G8991 Other PT/OT goal status G8992 Other PT/OT D/C status Other PT/OT Subsequent G8993 Sub PT/OT current status G8994 Sub PT/OT goal status G8995 Sub PT/OT D/C status

8 DEFINITIONS OF G -CODE CATEGORIES Functional limitation as defined by the ICF encompasses both activity limitations and participation restrictions

9 MOBILITY: WALKING & MOVING AROUND Walking short or long distances, on different surfaces, around obstacles Crawling, climbing, running, jumping, swimming Moving around within the home, outside the home, using equipment Moving around using transportation, driving

10 CHANGING & MAINTAINING BODY POSITION Changing or Maintaining the following Positions: Lying down, Squatting, kneeling, sitting, standing, bending, shifting center of gravity Transfers

11 CARRYING, MOVING & HANDLING OBJECTS Lifting and carrying objects in the hands, arms, shoulders, hip and back Moving objects with lower extremities Fine hand use; picking up, grasping, manipulating, releasing Hand and arm use; pulling, pushing, reaching, turning, twisting

12 SELF-CARE Washing and drying oneself Caring for skin, teeth, hair, nails Toileting Dressing putting on & off clothing, footwear Eating, drinking, looking after one s health

13 HOW TO CHOOSE? When the patient has more than one limitation, the therapist will need to determine which functional limitation is primary Most clinically relevant to a successful outcome for the patient The one that would yield the greatest functional progress The one that is the greatest priority for the patient

14 SEVERITY/COMPLEXITY MODIFIERS Modifier Impairment Limitation Restriction CH 0% impaired, limited or restricted CI At least 1% but less than 20% CJ At least 20% but less than 40% CK At least 40% but less than 60% CL At least 60% but less than 80% CM At least 80% but less than 100% CN 100%

15 GUIDELINES FOR SELECTION OF THE SEVERITY MODIFIER Use the severity modifier that reflects the score from a functional assessment tool or other performance measurement tool, as appropriate Use your clinical judgment in the assignment of the appropriate modifier. Although CMS has recommended the use of a tool, they are not requiring it Document in the medical record how you made your selection so the same process can be followed at succeeding assessment intervals

16 FUNCTIONAL MODIFIER CONVERSION CALCULATOR

17 STEP 1 STEP 2

18 GRID Functional Gait Assessment Score C Modifier 30 CH CI CJ CK 6-11 CL 3-5 CM 1-2 CN

19 G-CODE REQUIREMENTS Each reported functional G-code must also contain the following essential line of service information: Functional severity modifier in the range CH CN Therapy modifier indicating the discipline of the POC (GP, GO or GN) for PT, OT, and SLP services, respectively Date of the corresponding billable service Nominal charge

20 G-CODES REQUIREMENTS CON T In most circumstances, 2 G-Codes are required: For evaluations and progress reports: Current status and Goal status For Discharge note: Discharge Status and Goal status 3 G-Codes are required: When patient is seen for a one time visit

21 DOCUMENTATION REQUIREMENTS The G-codes and severity modifiers used in functional reporting are also required to be documented in the patients medical records of therapy services at the time of each required reporting, on the same date of service.

22 DOCUMENTATION STRATEGY Evaluation & Progress Report Notes G-code Severity Modifier Modifier Rationale for Severity Modifier Current Status G8978 Mobility G8981 Body Pos G8984 Carry G8987 Self-Care G8990 Other G8993 Sub Other CH 0% CI 1%-19% CJ 20%-39% CK 40%-59% CL 60%-79% CM 80%-99% CN 100% *** Goal Status G8979 Mobility G8982 Body Pos G8985 Carry G8988 Self-Care G8991 Other G8994 Sub Other CH 0% CI 1%-19% CJ 20%-39% CK 40%-59% CL 60%-79% CM 80%-99% CN 100%

23 DOCUMENTATION STRATEGY CONT. Discharge Note G-code Severity Modifier Modifier Rationale for Severity Modifier Goal Status G8979 Mobility G8982 Body Pos G8985 Carry G8988 Self-Care G8991 Other G8994 Sub Other CH 0% CI 1%-19% CJ 20%-39% CK 40%-59% CL 60%-79% CM 80%-99% CN 100% D/C Status G8980 Mobility G8983 Body Pos G8986 Carry G8989 Self-Care G8992 Other G8995 Sub Other CH 0% CI 1%-19% CJ 20%-39% CK 40%-59% CL 60%-79% CM 80%-99% CN 100% ***

24 EXAMPLE Evaluation & Progress Report Note G-code Severity Modifier Modifier Rationale for Severity Modifier Current Status G8984 Carry CM 80%-99% Patient scored 85 on DASH with 8/10 Pain reported Goal Status G8985 Carry CJ 20%-39%

25 AUDITS RECOMMENDED MR # Pt Name # of Visits (as of xx/xx/13) Evaluation Documentation: Functional codes and modifiers documented, and rationale for severity modifier documented in note, and agrees with note content. Circle One: Date of Service: Y N / / Progress Report (or Discharge) Documentation: Functional codes and modifiers documented, and rationale for severity modifier documented in note, and agrees with note content. (min every 10 visits) Circle One: Date of Service: Y N NA / / Billing: Functional codes and modifiers in documentation correspond to bill entries. Ensure presence of 2 G codes, each with a severity (C) modifiers, and discipline modifier (GO,GP or GN) Circle One: Y N Description of Deficiencies / Errors

26 ADDITIONAL REQUIREMENTS TO CONSIDER LCD 26884: (effective 11/1/2012) Progress reports will be required every 5 visits where therapy exceeds the cap was added to Documentation Requirements. As per CMS, functional reporting is not required at that time. Still required min every 10 visits. Medicare Secondary: As per CMS, all Medicare requirements apply, including functional reporting

27 RESOURCES CMS CMS IOM Publication , Medicare Benefit Policy Manual, Chapter 15, Section Medicare University LCD for Outpatient Physical and Occupational Therapy Services (L26884)