Clarifications on Claims Based Outcomes Reporting (CBOR) and G-codes

Check out the most common questions asked about G-codes

CMS started requiring Claims-Based Outcomes Reporting (CBOR) with Medicare Part B claim submissions on July 1, 2013. Here are many of the questions asked during Mediware’s webinars on the topic and questions submitted to us by email. Check back for updates, or submit your own questions by emailing This email address is being protected from spambots. You need JavaScript enabled to view it. .

Other popular CBOR resources: 

CMS’ MLN Newsletter.

The Health Care Code Lists are updated 3x a year for CARC and RARC. 

 CMS Final Rule.

Mediware as a company is not able to recommend outcome measures. We advocate collaboration with discipline specific professional organizations and networking, along with research driven articles to assist in appropriate tools selections. Our CBOR calculator may assist you in converting your assessment to a functional code. It is located here: http://www.mediware.com/rehabilitation/tools/item/g-code-conversion-calculator

 

Do you have to use a standardized outcome measure?

Yes, a standardized outcomes measure is recommended. Professional judgment can be used when selecting the G-code and scoring the functional modifier; however, in 2008, CMS updated the manual to include more requirements for functional outcomes reporting. Pub. 100–02, Chapter 15, Section 220.3, Subsection D) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Are progress notes required every 10 treatment days or only when the primary measure changes?

In addition to a change in the Primary Measure, updates to G-codes must be: no less than every 10 treatments days (evaluation counts as day 1), when there is a significant change in condition, when a re-evaluation procedure code is billed, a change in primary condition,  or upon discharge from care.

Does SLP have a Subsequent Functional Limitation code? Do not see it listed on the chart.

No, it does not.

If the mandatory reporting date is July 1, 2013, does that mean that therapy services provided in June and billed (institutional) in July…

…should have the G-codes and modifiers attached?
G-codes and modifiers must be on claims with the date of service (DOS) July 1st and on. (G-Codes and modifiers are required as of January 1, 2013 however, CMS will not start imposing penalties until July 1, 2013).

Will these CMS guidelines be adhered to by the non-traditional Medicare plans, i.e. Advantage Plans?

The current regulations only state Medicare Part B.

Can speech use NOMs and OT/PT use another tool?

Yes. PT, OT, and SLP will independently submit their own G-codes and modifiers using either a common or separate measurement instrument(s). There is no requirement to use the same instrument across disciplines. The GN, GO and GP modifiers must be appended to the G-codes to distinguish the disciplines.

Will there still be monetary caps?

Therapy caps are an entirely different and independent process than CBOR. There was a federal register post to update therapy caps to $1900 for CY2013. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2600CP.html

Are G-codes meant to replace other documentation?

No. In 2008, CMS updated the manual to include more requirements for functional outcomes reporting (Pub. 100–02, Chapter 15, Section 220.3, Subsection D). They assume everyone is already following these requirements and adding 2-4 additional G-codes on the claim are the only additional burden.

Can you resubmit the last visit with a discharge code if you didn’t realize the patient would be discharged?

If you did not plan on discharging the patient at that visit and no outcomes measure has been assessed, then you do not submit G codes with that visit, however, if measurements were completed you may report these with the discharge code for the date of service it was rendered. If this requires amending the bill that is acceptable and must be worked out with your billing department.

How can I edit a bill?

Generally a uniform bill is processed only once per month by your billing department. You have time to correct a claim before it is released and have your billing department correct the bill. If it has already been released to the MAC contractor, you can also submit an edit to the bill. (Note: Therapy Cap reimbursements are “first come-first served”; it may behoove you to increase the frequency of billing submissions-check with your MAC to determine if submission frequencies are restricted. CMS PROCESSES CLAIMS BASED ON THE DATE THE CLAIM WAS RECEIVED, NOT DATE SERVICE WAS PROVIDED.)

Many outcomes measures have ordinal responses which do not convert well to a % impairment.

True. CMS has provided guidance on how to convert scales that have an upper and lower bound; however, many scales do not convert linearly (100% Functionality = 0% Impairment). It must be assumed that those measures should not be used or you can rely on the ‘therapist judgment’ discussion and let the therapist select the functional impairment modifier directly. Descriptions to allow repeatability by subsequent therapists is necessary when using alternate outcomes measures.(Remember: Within Normal (functional) limits FOR THIS PATIENT should be considered.)

Therapists write their own functional goals. Will this be an issue as we move to the new G-codes?

As long as the goals are functional and the documentation contains the G-codes with modifiers somewhere, the requirements will be met. This will require the therapist to document how the score was reached so it can be repeatable.

Our EMR is CMS certified. Should they be ready for this?

No. CMS does not certify systems, ONC (Office of the National Coordinator) does. That certification is related to technical specifications for privacy/security, data collection and system interoperability. It is completely independent from CBOR and many other processes governing therapy practice.

What about Neuro patients (Parkinson’s for example) where maintenance is just as important as progression in functional goals…

…how would entering the G-codes be impacted?
CBOR is independent from medical necessity and justifications for payment of therapy services. A patient’s reason for therapist must be made as a clinical and business judgment and stand on its own merit. If the patient/therapist decides therapy is reasonable and necessary and services are rendered, you must submit G-codes to get paid. Whether or not the G-codes change will not determine payment. In some instances you will need to consider the “Other Impairment category.” Regarding necessity, refer to the following website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf. The following statement was taken from the above link:
Specifically, in accordance with the settlement agreement, manual revisions will clarify that coverage of therapy “…does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”

If the therapist/patient determines the G-code/modifier and the business office staff enter the data, is there a mechanism/form worked…

…out/recommendation to efficiently transfer that information from one to another?
CMS mandates that a licensed therapist denotes the code on the date the service was provided. Mediware’s MediLinks applications are fully interoperable between the therapist coding and those codes being transmitted for billing.

If a patient self-discharges before the 10th visit, what discharge code and modifier would be used?

You do not have to supply a discharge G-code if the patient self-discharges and you do not have a reasonable estimate of their progress.

If a patient is being seen for two separate diagnoses with two separate functional problems would two G- codes be needed for the initial goals?

From CMS: Assuming the same provider submits the claim for services under both POCs, only one functional limitation can be reported at a time per discipline. You will need to decide upon which POC Functional Reporting will occur. Treatment days for both conditions are counted towards the reporting frequency – counting each treatment day towards the total number of days the beneficiary received services, under both POCs. Note: It counts as one treatment day when services are received on the same date of service under both POCs.

How would G-codes be used for PT wound care clinics and debridement?

CMS provides impairment categories of “other” PT/OT G-code sets, especially when the beneficiary’s functional limitation is not described by one of the four (4) categories of functional limitations or the beneficiary is not being treated for a functional limitation.

How does this system work for patients with lymphedema due to breast cancer? These women don’t necessarily have functional limitations…

…but are at risk for infection if the lymphedema isn’t managed.
CMS provides impairment categories of “other” PT/OT G-code sets, especially when the beneficiary’s functional limitation is not described by one of the four (4) categories of functional limitations or the beneficiary is not being treated for a functional limitation.

Where do these codes go on the HCFA form (uniform bill – aka:UB)?

CMS has not published visual instructions for specific claims processing.   Some organizations such as APTA have published snapshots of a billing document to help you. The detailed description is part of the Medlearn Matter documents; (MM8005). A person that normally bills will understand these guidelines.

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, e.g., a penny, for institutional claims submitted to the FIs and A/MACs. For professional claims, a zero charge is acceptable for the service line. If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included.

How does one document G-codes for patients who are only seen for one visit for a CMC splint or post surgical splint?

CMS states in their CR8005 MLN Matters that one time visits must be coded with three sets of G-codes and modifiers for initial, goal and discharge. It can be viewed here: http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/MM8005.pdf.

Can you enter more than one primary G code at a time? If not, what is recommended if a patient has multiple deficits that will be treated simultaneously?

The primary deficit for each discipline is reported and the GN, GO, GP modifiers must be applied. If OT is seeing the patient for both memory and difficulty carrying items, only the one area of greatest clinical/treatment focus should be reported. Once the primary is reached, the secondary will become the primary and can be reported at the next visit once the initial has been discharged.

What are considered “composite functional tools?”

This is not defined within the regulations.

When billing as a hospital would you bill the goal G-code on each claim?

When functional reporting is required on a claim for therapy services, two G-codes will generally be
required. Two exceptions exist:
1. Therapy services under more than one therapy POC. Claims may contain more than two non-payable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.
2. 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 on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.
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, e.g., a penny, for institutional claims submitted to the FIs and A/MACs. For professional claims, a zero charge is acceptable for the service line. If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included.

How would we use a progression from walking with a walker to a cane?

Moving from one assistive device to another is not likely to meet CMS requirements for a skilled therapy intervention. CMS is requesting documentation on functional improvements and if this cannot be defined when documenting from Walker to Cane incorporating Mobility, such as the skill sets of a therapist to improve balance and righting reactions, etc., that are measureable, the change in device alone is not the focus.

Does coding (G-codes and modifiers) have to be in billing or just in charting documentation?

The G-codes and modifiers must be in both documentation and on the claim. Per CMS: “The therapist or physician/NPP furnishing the therapy services must not only report the functional information on the therapy claim, but, he/she must track and document the G-codes and modifiers used for this reporting in the beneficiary’s medical record of therapy services.”

Can a PTA report on the 10th visit?

From CMS: Yes, the therapy assistant who furnished the services can report the G-codes and modifiers to begin reporting for a second functional limitation when a therapist previously determined the functional information.

For speech evaluations, what happens in the case that a swallow study is ordered and no treatment is indicated/delivered? There would be no treatment indicated and therefore no functional goal.

This would be treated as a one time visit and thus require 3 sets of G codes/modifiers (Current, Goal and Discharge). It is understandable if there is not gain on the G codes as this is an evaluative procedure.

Do we really need to write goals, if we are using these tools and scales to justify our care?

Yes. CMS maintains G-codes are derivatives of the written and more explicated functional goals. In 2008, CMS updated the manual to include more requirements for functional outcomes reporting. Pub. 100–02, Chapter 15, Section 220.3, Subsection D) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf They assume everyone is already following these requirements and adding 2-4 additional G-codes on the claim are the only additional burden.

As of July 1, what information will need to be submitted for patients who have already been evaluated? Will we need to enter eval G-code…

… at that point?
If you have been submitting Functional Reporting data during the testing period, you can continue reporting and will not need to restart Functional Reporting on the first date of service (DOS) on or after July 1, 2013 for episodes of care for which Functional Reporting began during the testing period. In other words, for those episodes of care, for which you included Functional Reporting on the claims for DOS prior to July 1, 2013, reporting after July 1, 2013 is required at the next regularly scheduled reporting.

Does speech choose a G-code for each of the seven areas if the patient has deficits and they are working on multiple areas in therapy…

… or do they choose one of the seven?
Only the primary area of impairment should be coded.

Can you explain how you enter the AM-PAC composite score into the other category for PT, OT and SLP?

The AM-PAC has three domains: Daily Activity, Basic Mobility and Applied Cognitive. Each domain yields a score that converts to a functional modifier. The therapist selects the functional area (G-code) and then applies the modifier that the AM-PAC displays. The Basic Mobility domain maps to either walking or changing position. The Daily Activities maps to either carrying/moving objects or self care. The Applied Cognitive scores can be allocated to swallowing, motor speech, spoken language comprehension, spoken language expression, attention, memory or voice.

Do you use three separate composite scores for each area of the AM-PAC for the different disciplines? For example, applied cognitive…

…score would go under SLP other category?
Yes, sort of. Because there is practice ‘bleed over’ between functional areas and the disciplines that treat them, it is better to think of the AM-PAC domains as mapping to specific functional areas than disciplines. The Basic Mobility domain maps to either walking or changing position. The Daily Activities maps to either carrying/moving objects or self care. The Applied Cognitive scores can be allocated to swallowing, motor speech, spoken language comprehension, spoken language expression, attention, memory or voice.

Does the KX modifier need to be applied on the new G-codes?

From CMS: No, the KX and 59 modifiers are not appropriate and should not be used on the line of service with the functional G-codes.

Can the DASH be used for the outcome scale?

From CMS: CMS does not have a list of approved or endorsed functional assessment tools. MediServe has made the DASH available for our outcomes calculator at: www.mediserve.com/cbor.

Does this Final Rule also include inpatient acute hospitals?

From CMS:
Functional Reporting is required of:
• Skilled Nursing Facilities (for beneficiaries in a Part B stay)
• Rehabilitation Agencies
• Home Health Agencies (for beneficiaries who are not under a Home Health plan of care, are not homebound, and whose therapy or other services are not paid under the Home Health prospective payment system)
• CORFs (PT, OT, and SLP services)
• Hospitals, including beneficiaries in Outpatient and Emergency Departments, and inpatients paid under Part B
• Critical Access Hospitals
• Therapists in Private Practice: Physical Therapists (PTs), Occupational Therapists (OTs), and Speech Language Pathologists (SLPs)
• Physicians: Medical Doctors (MDs), Doctors of Osteopathy (DOs), Doctors of Podiatric Medicine (DPMs), and Doctors of Optometry (ODs)
• NPPs: Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs)
• Observation services are, by Medicare’s definition, outpatient services in the hospital. As such, Functional Reporting applies. Once the decision is made to admit the beneficiary to the inpatient hospital, Functional Reporting no longer applies. If the beneficiary’s treatment was furnished on just one date of service, the therapist would report all three (3) G-codes in the set for the functional limitation being reported.

How do we convert to the 7 point scale if the outcome measure is not on your list? Can it be a straight percentage, i.e. 40/56 = 71%?

First, determine if the scale has an upper and lower bound. If it does, you can take your value and divide by the total range of the scale to get the percentage. Next, you have to decide how to handle the fact that the functional modifier scale is an impairment scale. If the higher the score means the higher the patient performs, you’ll have to use one minus your percent to get the percent IMPAIRMENT, not the percent of functional improvement.

Do you have to complete G coding and C modifiers on patient that have Medicare Part B as secondary?

From CMS: Yes, Functional Reporting is required when Medicare is the secondary payer.

How do you write out the codes in the documentation?

I have a patient that becomes eligible for Medicare Part B midway through his established therapy plan of care. On the first day…

…that Part B will be billed…does the therapist have to submit G codes and modifiers…as it might not be time for a progress summary. Or, can they wait till a progress summary is due?does the therapist have to submit G codes and modifiers…as it might not be time for a progress summary. Or, can they wait till a progress summary is due?
It’s a new insurance. They would be discharged from the previous payor with a new start date, evaluation and plan of care. G codes start that day.

If the therapist sets a goal status G-code and the patient makes more progress than the goal severity modifier how do they proceed? …

…Can the current status be better than the goal status or can they change the goal status modifier?
MediServe recommends that if your documentation demonstrates you have surpassed your goal-you should discharge the goal and the patient, or discharge the goal and select a new Primary Impairment. (You must be able to demonstrate a continued need for skilled therapy services in your documentation if an update to the goal is desired).

What functional assessment tool should SLP use for Laryngectomy patients using TEP? …

…For treatment of dysphonia due to vocal nodules? the NOMS released by ASHA does not support voice orders
We believe that clinical questions such as that might best be answered in forums that represent the treatment of those types of patients. We are not trying to guide persons on which tools to use and I am not even certain we have tools presently loaded that may meet research driven measurement scales for the population of patients with laryngectomies.
My guess is that someone in outpatient that has been seeing patients with tracheoesophageal puncture (TEP) would have some sort of scale for ability to express themselves for basic daily needs and or community level communication. I would follow that trail for review of literature etc. that would provide scales that can translate to the impairment model.
This most likely would be categorized under other SLP functional limitation unless you felt the condition was temporary; if you are working on Voice production and then G code for voice would be appropriate. I think the real answer will lie in the goals that the staff set for the encounter. Is the strategy for phonation or the ability for someone to understand given alternative training devices etc.

How to assign a code to patients who require an augmentative communication system?

We believe that clinical questions such as that might best be answered in forums that represent the treatment of those types of patients. We are not trying to guide persons on which tools to use and I am not even certain we have tools presently loaded that may meet research driven measurement scales for the population.
My guess is that someone in outpatient that has been seeing patients with augmentative communication issues would have some sort of scale for ability to comprehend and express themselves for basic daily needs and or community level adaption of use. I would follow that trail for review of literature etc. that would provide scales that can translate to the impairment model.
This most likely would be categorized under other SLP functional limitation unless you felt the condition was temporary and you are actually working on Voice so that you can show improvement and reduced need or use of the augmentative device.

If a Progress Note is done on the 7th visit for a Medicare patient, can the Primary Functional Limitation update be skipped…

…(using the branch list item Update/Add NON-primary impairments) and then be updated on the 10th visit using a Treatment Note? The reason for the question is to determine if it is possible to keep a consistent update Primary Funcational Limitation cycle of every 10th, 20th, 30th, etc visit using a Treatment Note (for ease of tracking and therapist identification) despite when a Progress Note or Re-Evaluation is done during the course of care.
Specifically, functional reporting, using the G-codes and modifiers, is required on therapy claims for certain DOS as described below:
• At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;
• At least once every 10 treatment days — which is the same as the newly-revised progress reporting period — the functional reporting is required on the claim for services on same DOS that the services related to the progress report are furnished;
• The same DOS that an evaluative procedure, including a re-evaluative one, is submitted on the claim (see below for applicable HCPCS/CPT codes);
• At the time of discharge from the therapy episode of care, if data is available; and,
• On the same DOS the reporting of a particular functional limitation is ended, in cases where the need for further therapy is necessary.

We frequently evaluate Medicare patients during a single pre-operative visit, which includes…

…assistive device fitting, gait training, etc. Patients are then seen the day following their surgery to begin the rehab process. Since a significant change in status (surgical procedure) is anticipated, how should G-codes be reported for this episode of care? Should the pre-op visit be treated as a one-time visit (i.e. report current/goal/discharge G-codes for one functional limitation) with a new functional limitation chosen at the post-op visit? OR should the pre-op visit include current and goal G-codes for one functional limitation, with updated G-codes reported at the post-op visit (even if updated G-code reflects a decline in current status)? Please talk to your billing department. Any therapy that is associated with a ‘surgery’ is generally a bundled ancillary payment and will not be paid by the fee schedule. If that is true, your care has always been bundled with and paid for by a different ‘service’ type other than fee for service. If you find out it is NOT a bundled service, then treat it as a “one time visit” and submit all three codes.

Does the plan of care need to be certified by the physician at the pre-op visit and then re-certified at the post-op visit?

On the post op visit, do a re-evaluation and submit all three codes unless subsequent visits are anticipated.

If we have a Medicare account under which two therapists of the same discipline are treating, say Lymph and Vestibular…

…does each Program at time of EVL assign a G-code and modifier? If so there would be two G-codes with associated modifiers on the account and I am not sure CMS can handle that. Thoughts? I am wondering if MediServe has any guidance. It seems to me that only one program can apply G-codes to a shared account. The account is shared so only one consolidated bill goes out. If the program assigning the G-code and modifiers D/Cs before the program who did not initially assign a G-Code and modifiers, then the program who didn’t assign the G-code would need to assign one the visit after the D/C by the program who had assigned the initial G-code and modifier. Does that sound correct?
CMS states that the clinic decides WHICH is the most functionally disturbing. Submit modifiers for that one only until discharged and then you can pick up the second to apply the g-coding principles. Suppose the second one was discharged before the first was completed. (oh well;…it’s on the same bill and doesn’t matter’. It is only looking for the condition originally submitted as the ‘most’ functionally disparate requiring care. Now, let’s consider the first item was discharged while the second continues; then the d/c code goes in on the final bill and the NEXT time a bill is created you would pick up the second code and begin reporting that item. ” Also this is from CMS’ CR8005 MLN Matters. However it seems that they are stating “multiple POCs” being multiple disciplines and not concurrent episodes of the same discipline: 1. Therapy services under more than one therapy POC. Claims may contain more than two non-payable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.

We may be using the PSFS converter and noticed it’s based off a 0-10 scoring range…

…We document 3 segments, each at 0-10. How is your converter calculated for this test?
Our take on this is that this particular scale is a Likert Scale and it is not cumulative. Essentially the therapy practice will ask the patient WHAT FUNCTIONAL items they believe are difficult for them to perform and are specifically related to the reason for the present therapy intervention. They score this on the scale to 10.The therapist then CHOOSES which one they will show the most impact to as a GOAL given the particular functional problem (reason for the therapy interaction), their assessment and goal they determine can be achieved given their working together.That therapist will then only use ONE of those functional items to attach their initial and goal performance measurement to. At discharge they will then report that specific outcome based on the same area they chose to impact given their therapy interventions.

Is the the CBOR reporting in MediLinks able to track the 10th visit if Progress Note report writing is offset due to M.D. visits…

…So, a Progress Note is written on the 7th visit due to an M.D. appt, will the CBOR reporting in MediLinks be able to notify when we are approaching or have passed the 17th visit? The CBOR Exception report only looks for coding errors/issues. However in MediLinks 2013 there is new functionality that tracks the Plan of Care /progress note and lets the therapist know if they are approaching the 10th visit. This counter is re-set after every Progress Note is documented. It is designed to help keep you compliant.

I know that a G-code must be accompanied by a CPT code of a eval 97001 or a re-eval 97002…

…We have been told that Medicare does not want therapist to charge for a re-eval unless there is a significant change is the pt. status?? I do not see updating the pt current status as a re-eval? Please clarify?
CMS has recently changed the process to allow any CPT code to accompany G-codes when you are NOT documenting an Initial Eval or Re-eval. Therefore, the CPT code does not have to be one of the 15 original Evaluative CPT codes that CMS specified (e.g., 97001, 97002, 92616, etc.). If, for example, you are doing a treatment note and update your primary impairment goal to drop g-codes, you must also include a CPT code.

We were advised to use 97542 for wheelchair evaluations. This is not listed as an “eval code” to link with G-codes…

…Should we be billing 97001 or 97003 for wheelchair evaluations. Would it be appropriate to use 97001 and 97542 for a seating evaluation/assessment?
Ingenix Coding and Payment guide. (Can be obtained at www.shopingenix.com) as it is a guide book on use of CPT coding for therapy practice. “Code 97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes does appear to be a code that is used (using the 8 minute rule) to perform ‘assessments, fitting, and adjustments, and instructs and trains the patient in proper wheelchair skills (e.g., propulsion, safety techniques) in their home, facility, work, or community environment. This requires direct contact and may be billed in 15-minute units.” Since our evaluation codes are NON-Timed codes and can also be used in conjunction with treatment and other assessment codes it can be used with the 97542 code. I also checked the CCI edits and those two are allowable at the evaluation visit. If you use those two together you must use the first 22 minutes as the evaluation time and the remainder as the Wheelchair management/assessment code using the 8 minute rule for all remaining time to determine the TOTAL time of treatment. Using this combination allows you to easily report using the G code in the standard method for Medicare Part B patients at defined frequencies (Initial, progress summary-on or before 10 visit, re-eval and discharge). Thus in your example, if the patient is Medicare Part B, and you are completing an initial evaluation…you would complete Gcodes and C modifiers. See the Medicare Benefit Policy Manual Chapter 15; Section 220.4 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf.

We do not have SLP so our OT does swallowing assessments. Can OT use the swallowing G-codes G8996, G8997, G8998?

We cannot interpret guidelines as that are a regulatory interpretation that is best left to your legal review department and or compliance department within your facility. However, we can guide you to the CMS regulations that stipulate practice interpretation for the various disciplines and the application of functional Coding.Go to this first web link and review the Medicare Benefit Policy Manual Chapter 15 Section 220.1.2 (Talks about required POC information). 220.3 (Documentation for Therapy) 220.4 Functional Reporting requirements and last but not least section 230.2 that discusses OT practice requirements. Be sure to review the Dysphagia section under SLP because they talk about appropriate specialty training and I do know that some other clinicians get certification etc. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. As far as the use of modifiers is concerned there is quite a bit of language that states there could be some flexibility in who utilizes the coding. In the ‘SLP’ area it states these codes are ‘typically seen when receiving SLP’… and in the PT/OT section it states ‘generally’ OT/PT. This would lead persons to believe that because the g codes are being asked to be used with the GO, GN, GP modifier that the use in any combination is available as long as it was appropriately reported with the specific documentation required and that the individual had the appropriate training. Now, if you were to submit and your Medicare contractor does not accept that combination you should discuss that with them in light of these regulatory guidelines and ask for further clarification – maybe even by MedLearn Matters so they will publish something more direct to your needs.http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf. In the link above you want to go to 100-04; Chapter 5 Section 10.6. They discuss line of service reporting. Look under section 10.6.G.

If a patient sees an OT and a PT on the same date of service, can both services use the same G-code?

Yes, because you must append the G code with a GN, GO and GP modifier to distinguish the separate disciplines plan’s of care.

I was trying to use the converter for a TUG test to determine the best G code modifier for my patient. …

…My patient averaged 23 seconds, however the converter is just asking for a score between 10 to 20. Please advise what TUG test scoring you’ve used for this converter. The values “20 to 10″ are considered within the “impaired ranges” normally seen. Less than 10 is considered normal mobility (0% impaired) and greater than 20 indicates additional assistance and examination/intervention (100% impaired or greater). The following summarizes what most of the literature reviews communicate (I have included a link to the more clinically relevant websites discussing timed trials and normative test values):
Timed Up and Go test
From Wikipedia, the free encyclopedia
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The Timed Up and Go test (TUG) is a simple test used to assess a person’s mobility and requires both static and dynamic balance.
It uses the time that a person takes to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down. During the test, the person is expected to wear their regular footwear and use any mobility aids that they would normally require. The TUG is used frequently in the elderly population, as it is easy to administer and can generally be completed by most older adults. One source suggests that scores of ten seconds or less indicate normal mobility, 11 – 20 seconds are within normal limits for frail elderly and disabled patients, and greater than 20 seconds means the person needs assistance outside and indicates further examination and intervention. A score of fourteen seconds or more suggests that the person may be prone to falls. Alternatively, a recommended practical cut-off value for the TUG to indicate normal versus below normal performance is 12 seconds. A study by Bischoff et al. showed the 10th to 90th percentiles for TUG performance were 6.0 to 11.2 seconds for community-dwelling women between 65 and 85 years of age, and determined that this population should be able to perform the TUG in 12 seconds or less.TUG performance has been found to decrease significantly with mobility impairments. Residential status and physical mobility status have been determined to be significant predictors of TUG performance.[6] The TUG was developed from a more comprehensive test, the Get-Up and Go Test.
Research has shown the Timed up and Go test has excellent interrater (intraclass correlation coefficient [ICC] = .99) and intrarater reliability (ICC = .99).[8] The test score also correlates well with gait speed (r = -55), scores on the Berg Balance Scale (r = -.72), and the Barthel Index (r = -.51).Many studies have shown good test-restest reliability in specific populations such as community-dwelling older adults and people with Parkinson’s disease.
Additional resources:
Seconds Rating
20 Impaired mobility (this is from the website-not a typo)
Source: Podsiadlo, D., Richardson, S. The timed ‘Up and Go’ Test: a Test of Basic Functional Mobility for Frail Elderly Persons. Journal of American Geriatric Society. 1991; 39:142-148 http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903
http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi/timed_up_and_go_test.pdf, http://www.unmc.edu/media/intmed/geriatrics/nebgec/pdf/frailelderlyjuly09/toolkits/timedupandgo_w_norms.pdf. Additionally, if a value greater than 20 is entered, (in this case, I entered 30-value defaulted to 20 when calculation was performed) the following is displayed:modifier scale

What do you think the impact will be for those who show a decline in the follow-up testing – we have many pts who score lower…

…than their initial for multiple reason however they are showing progress in the clinic and with objective measures?Nothing differently.CBOR does not currently impact payment.You better have good documentation for medical necessity justifying ongoing care. Also, you might want to invoke the ‘clinical judgment’ option and pick a different modifier. You just need to document the inconsistency well.

In the design matrix I might have missed it but I didn’t see a Branch that prompts the therapist to document how they determined ….

…the primary impairment (AM-PAC, BERG, TUG, DASH, NOMS, collection of tools, etc…Selection list or Text Response) which I believe is required as part of the new CMS requirements.From CMS presentation:Preparing for Therapy required Functional Reporting Implementation in CY 2013 “Therapists will need to document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.” National Provider Call December 12, 2012
Our Standard Content has a branch used by clinicians to document the determination of Primary Impairment prior to documenting the CBOR areas. Additionally, we have minis that clinicians can pull in as they deem necessary based on how their templates are configured and which workflow they prefer. Since the determination of primary impairment branch already existed, and clients have been documenting this previously it was determined to not be necessary in our CBOR content.

Can someone tell me what the logic would have been for building the speech g-codes for PT?? For example – why would…

…someone build G Code Swallowing for PT with modifier GP, etc.? We built ours to cover all possibilities. You can leave them out!

Does G coding have to be submitted the same day of service, or the same day as billing?

The G-coding must occur on the DATE OF SERVICE within the billing document.
Generally facilities wait and bill all services in one month on one uniform bill. Most often it is within the week following the previous month. Talk to your billing department to see what day they ‘drop’ the bill to your fiscal intermediary (MAC). This always gives you ample time to correct and validate anything from the previous month before bills are dropped.

Are revenue codes required on the line of service for the non-payable functional G-codes for institutional claims?

Yes, on the line of service for each nonpayable functional G-code, use the appropriate therapy revenue code – 420, 430, or 440 – to correspond to the therapy modifier – GP, GO, or GN, respectively.
So you are correct, if at any point you are able to determine the discharge code for the outcome utilized; you should be able to amend your bill on the last date of service with the goal and discharge modifier.
Be aware though that this is above and beyond the required expectation. MM8005 states that if the patient does not show for a last visit and you do not have a discharge assessment available you do NOT have to provide a discharge modifier.

If we have a patient that has a wound and is being seen weekly, how do we do the discharge g-codes if on the last day….

…they come in (which we will not know in advance) if we do not have a charge for that day? CMS has stated that if an assessment was not made on the day of discharge because the patient did not come to report a final that the discharge score would not be required. You should have at the very least the initial and goal and then any updates for the 10 day visit reporting. The 10 day visit reporting (or sooner if you desire) should have the CPT code for the visit AND the present status & goal attached to that date of service.So, for example, if you did not meet 10 visits yet you do not have a discharge status. YOU CAN amend your LAST VISIT in your billing system if you have documented information to complete a G-code and then add the g-code and modifier to that visit. In essence you are reporting a sooner than 10 day required update if you wish to do that. If your plan continues at all though you have to begin your 10 day count from the progress visit.

Do you know how I would select a G-code in re: diagnosis of incontinence? …

… Any test/measure forms that would provide a modifier? It would go under self-care or ‘other’ PT/OT functional impairment. You would have to rely on practice standards for using a ‘tool’ that would provide measurable impairment. We cannot tell you or advocate which specific tool but believe you will find outcomes measurement in the literature for incontinence and the ability to show improved outcomes.

We noticed that in one of the CMS, MediServe Q&A that it was asked if there is one discipline OT seeing a patient for vestibular …

… and Lymph with 2 separate POCS how to do G codes. It states that CMS says the clinic decides which is most disturbing. Submit modifiers for that one until D/C and then you can PICK UP the second and apply the G coding principles. Further down it talks again about PICKING UP THE SECOND code.
Does this mean that there should be 2 g codes and modifiers from the beginning or just that when the first discharges you add another code on the next visit with the discipline who has not yet discharged. You must first discharge the first modifier and then at the following visit pick up the present status and new goal of the second area within this same episode of care.

Are g codes and modifiers required for Medicare replacement plans such as Aetna Medicare?

The original intent was Original Medicare only and not the part C HMO providers for Medicare. However, later in the Medicare instruction they stated that some HMO are requiring the codes and so you would have to ask each provider if they require it. We at MediServe would add that to the ‘authorization’ process any time a Medicare HMO patient was registered. Ask, do you require G code documentation with the billing?

A neuro patient that was being seen and making progress utilizing the PSFS was initially a CL and goal was set at a CJ…

…Patient progressed to a CK but then was admitted to the hospital. Upon returning to outpatient as a re-eval- 2 weeks later the goal and the outcome tool will remain the same but the patient is now back to a CL. Our concern is that the modifier will look as if the patient is declining although the documentation will support what happened. Is the recommendation to state that the goal will remain the same but change the modifier to a CL? (MediServe comment – opinion only) It was a practice of one of my facilities that any time a patient was admitted to ACUTE CARE (with a stay) that the Outpatient POC would be discharged. A RE-evaluation would be completed and a new approved POC in the event the admission in any way changed physician expectations. It also made neat episode changes at the medical record level and in the billing department. You may want to review the process with your billing department to see if they have the same expectations. IF so, you would neatly end the reporting as a ‘discharge’ and restart with three codes and the relapse as noted.

A patient has met the original goal of a CH for the mobility category as evidence by receiving a 56/56 for the BERG. …

…The therapist still wants to progress the patient in other areas that affect mobility and chose a different outcome measure. The concern is that now the patient will not be a CH with the new outcome metric and it could look like the patient is declining. Is the recommendation to proceed and the documentation will support the change or is it necessary to discharge that primary goal and create a secondary goal even if the mobility goal is truly still the area of focus? (MediServe comment – opinion only) CMS Guidelines state that if you are going to change the emphasis you should discharge the primary and then on the NEXT visit, pick up the new indicator and then restart your 10 day progress report cycle.

If you discharge the primary and on the next visit pick a secondary it has to be a different category, correct?

… Is there then no way to keep the same category of “mobility” and add a new modifier on the next visit? We do not believe they limited this. Your notes will show completely that the next ‘limiting’ functional area still relates to mobility and the tool you are using is…blank to set that standard of outcomes.

When performing a wheelchair evaluation with no plan of care, do we need to add g-codes to the claim

… if charging a wheelchair management? Since you are asking about G codes, I will assume this is Medicare. Medicare does not allow you to bill the patient without an evaluation code on the first visit. The outpatient regulations state everything that must be included in the documentation of the evaluation. The wheelchair code 97542 includes ‘assessments, fitting and adjustments’. That is for the wheelchair. Your evaluation is of the patient and the conditions you are evaluating to set up the wheelchair order and or training; therefore they are used in conjunction. Even if you did an wheelchair management service, you must drop an evaluation code for billing purposes to show the measurements, considerations etc of the persons condition that required the w/c assessment/fitting. Normally, persons will drop the evaluation and at least 1 unit of the w/c management. The coding book states that you must have at least 8 minutes specific to the w/c assessment itself in order to drop that code. Even if there is no additional plan of care, you would drop the one time visit code. See item # 2 on page 10 of the attachment for coding the one time visit, all three codes. In this case you would use ‘mobility’.

Just wondering what a good workflow would be for observation patients that start out as inpatient, than turn observation?

…We are finding that this is happening once in a while and therapies had already done the eval as an inpatient eval (no g codes). Are we expected to get another order from the MD if the patient goes to observation and then do another eval with G codes? This may not be a popular answer but we at MediServe think it will be good practice from this point forward for every patient treated in an acute care to have stated measureable GOALS that relate to function and the present status at the evaluation. Since patients stay in acute care for so very little time, at the very least one update if they are treated more than one week. Given this workflow, if the billing department should alert you ANYTIME in the future that a patient switched to observation status and or a patient was really a part B coverage only patient when they were in an inpatient bed, etc., you have the information you need to create the appropriate G-code for billing. Make sense? In fact, every time a therapist does an evaluation they generate a problem list and a ‘goal’ to meet for the time being. If the patient was only seen for assessment with no purpose for further treatment then you have all codes listed with ‘no impairment’ ratings. If people begin to think this is a pay for performance world and outcomes will be placed on all that we do, it will be easier in the long run to accommodate at a moment’s notice.

As a physical therapist in wound care, our question is how to add the modifier appropriately to 8990 “other” code….

… (1) What is the 100% (or 40 or 60% or whatever) we are basing it on to come up with CH vs. CJ etc.? (2) Our goals are wound closure, infection prevention & such related. (3) So do we start at 100% impaired (not closed wound) and progress to CH (100% healed & closed)? We are thinking an open wound is a limitation of the immune/integumentary system to fight off infection, etc. This link helped described outcomes measurement in the healing of wounds. We believe this site can provide you different tools depending on the nature of the wound problem and how you might be able to provide appropriate ‘healing’ or recovery/improvement of the wounds you treat. I would review the type of wounds you work with and to then utilize the tool most appropriate to that patient types. We know, for example that pressure wounds might be stage-able to describe the tissue depth but as far as surgical, burns etc., you are best reading the literature and adopting those that meet your needs. As long as you describe the methodology and it is repeatable for measurement, I agree that information that demonstrates change or improvement is far better than an ‘other’ classification. We just don’t know how CMS will utilize this information in the future and it would be unprofessional in my opinion to provide no information with an ‘other’ code when you can just as purposefully give progressive information using acceptable measurement for the conditions you personally are serving.

Will there be any new standard reports in MediLinks to collect and report this data?

Yes. MediServe has created a new exception/variance report to assist with CBOR documentation.

Does CMS require a G code set to be discharged? If so, is it required within the 60 days? Or, any time after the patient has been discharged?

No. although at the APTA conference we heard some intermediaries felt they were mandatory. Send them a fax of this SE1307 to prove it's not. CMS states they DO NOT require a discharged G-code if the patient did not return 'unexpectedly' - and a final assessment was not completed. Although this is true, we have been told that some finance departments INSIST they get a G-code and that their software will not let them discharge a chart without 'closing the loop' so to say. If that is true, I tell them to find the last time a code was documented in the note and to them place that code as the d/c code on the last date of treatment and reference the note WHERE it was actually assessed.This allows them to meet their HIS functions and certainly would be referenceable should the chart get a manual audit. See Page 3 of 10 SE1307.

If a patient had the gcodes reported at the 10th visit and then at the 14th visit the therapist billed a re-eval (97002), are the PQRS codes and additional gcodes needed again?

Depends on why the re-eval was done. You can only bill an eval or re-eval cpt on the same date of service as g codes are reported.  If the re-eval was for the same impairment then restating the present status and goal will enable payment and the ten day visit count begins again.  If the re-eval revealed a different impairment and it is secondary, then put present status, goal and discharge all in the same note.  It will be ignored and you continue counting ten days from the previous reporting. 

Now if the re-eval reveals an impairment that needs to be primary, then the therapist will put a present status, goal and discharge status for the previous impairment and then on the NEXT visit will pick up the new gcode; Present status and goal and will continue a new 10 day count with that day.  

We are getting numerous CO-45 and CO-59 denial codes for no reason on claims. What is medicare wanting or not wanting on the claims? We are billing the charges just like we always do.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm7050.pdf

See the change request /Medlearn Matter 7050 to explain these adjustments.  They have more to do with the multiple procedure payment reduction and nothing to do with the G-codes.

"Where claims are impacted by the MPPR, Medicare will return a Claim Adjustment Reason Code of 45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement) and a Group Code of Contractual Obligation (CO). "

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7564.pdf

"You may want to review MM7564, which advises providers that CARC 59 (processed based on multiple or concurrent procedure rules) will replace CARC 45 to indicate that the claim payment is subject to the MPPR.

If a G-code set is discharged within 60 days and the patient comes back within 60 days, does that G-code set need to be amended to be able to use the same G-code set or can we reinitiate the same G-code set without amending the discharged G-code?

No amending required. As long as you use a 'present status and goal set', you should be fine to bill on the first date of service after a discharge and or 60 day lapse. This will begin the 10 count toward the next report unless you choose to discharge or report sooner. 



Can G-codes still be submitted if the hospital account record has been closed?

Any 'bill' can be amended after the fact to add coding or correction. The billing department would know the UB-04 transaction code to allow that.

Can G-codes be submitted if after the end of the month? After 60 days?

G-codes can be submitted on any date of service billing. Generally, most facilities will wait 4-7 days into a new month to 'shore up all charges' coming through their outpatient departments to drop the previous months bills. If it is past 60 days the question is, "Was there a date of service or NOT?" If there is no date of service past 60 days there is no way to drop a bill unless you amend a previous bill on a date the patient was actually seen. If there is a date of service then you can do as we mentioned above and drop a present status and goal code for either the SAME impairment as before or a new one. Remember, in CMS' eyes the 'episode' was closed. You are actually creating the first reporting day of the next episode of care in their eyes.

Does CMS require us to have a % of discharges with G-codes?

We have not seen anywhere that a percent of discharges without codes creates any red flags. However, someone in an intermediary capacity might say, "Why are most of these patients not being 'officially discharged?" No sense in giving them cause for extra eyes on charts! If we were managing a facility at this time; we would perform self audits to see if there is any 'trending'. Is a specific therapist delinquent in communicating discharge codes and therefore just 'lets it go' because its not required. We might look at patient treatment diagnosis codes without discharge status codes to see if there is a subset of patient types that often don't wrap up services and then be more vigilant toward that diagnosis going forward in communicating a clear d/c date - or even assess that pt. category more often knowing I may get stuck with a hanging date and no assessment. We like closure personally so even if CMS doesn't require it, I would try to get d/c information on as many bills as possible as it's neater and cleaner in the long run.