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Written by: Darlene D'Altorio-Jones (1959-2015) on Thursday, May 23, 2013 Posted in: Outpatient Rehab

Procrastination seems like a worthwhile event if you are one of those persons that performs best under stress and against all odds meets the necessary deadline. However, if you are talking about the now infamous therapy G-Codes and impairment modifiers, you may have missed a ‘soft’ deadline without even noticing. As an optimist you believe that if you meet the ‘hard’ deadline (we’ll call that the billing deadline), everything will be just fine. In the experience of federal regulations and  published ‘effective’ and ‘implementation dates’, I am pretty sure the Medicare Audit Contractor will follow the change request documentation guidelines. It’s their job to hold providers accountable to updated documentation standards. If you don’t, you run the risk of non-payment. Let’s pay particular attention to the change request 8005. Then we can ask ourselves, “will non-payment only occur if electronic submission does not begin with July billing?”

I would not personally wager on a bet that the g-codes will ONLY affect payment if you do not begin using them at the billing level post July 1. (I’ll provide my rationale in a minute.) As promised, non-coding will immediately affect non-payment if you don’t include the outcomes codes on bills post July 1 for certain. Let’s ask this question however, “what if you later have an additional development request for a record charted after Jan. 1, 2013?” Do you have any concerns if you did not begin charting outcomes codes within that record?

You may be in for a retrospective ‘uh-oh’ if you really didn’t ‘Get Er Done’ as you should have according to change release (CR) 8005 or MM8005. So let’s review this topic in detail because providers are presently struggling with patients in ‘mid stream’ of the July 1 billing deadline. Many are not quite sure how Medicare wants the bill coded if the provider did not begin charting prior to that date and did not begin real testing to the electronic billing document as they were encouraged to do prior to July 1  using the new status code indicator ‘Q’ for reporting purposes only.


I’m now deferring to my logic and logic is not always the enforced process, so for now humor my bulleted points to ponder provided the following ‘facts’ known thus far:  Pay attention to bolded areas.

  • Prior to July 1 the information should be in the documentation at the very least but does NOT have to be on the bill (although they are providing a grace period to work it out through the billing department).
  •  pg 2 of 11 of MM8005:

Application of New Coding Requirements

“This functional data reporting and collection system is effective for therapy services with dates of service on and after Jan. 1, 2013. However, a testing period will be in effect from Jan. 1, 2013, through June 30, 2013, to allow providers to use the new coding requirements in order to assure that their systems work. During this time period claims without G-codes and modifiers will be processed. “

  • “Will be processed”  – I agree, means: will be paid as submitted given all other rules of billing have been followed.
  • To me, this states that you should have this information in your notes at the very least after January 1.  But, the payment penalty will not be invoked from Jan – June 30 as a grace to get the billing systems to work appropriately. In essence, the bill will still be paid. 
  • On a retrospective actual chart audit if requested for any other purpose, who knows if they will take back money previously paid if outcomes coding is not committed to the charted record per the change request published in December?
  • pg 8 of 11 of MM8005:

“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.

I feel these bullelted items above gives providers ‘hope’ that they can just pick up and begin reporting in the middle of an episode of care if that patient started services PRIOR to July 1. With the guidance above to REPORT the codes when they are required (post July 1 DOS) to the bill;  there are several scenarios that could occur. Until I hear otherwise with additional guidance awaited from CMS, this is what I might do: (Disclaimer:  always consult your compliance department and/or follow all CMS releases should they publish new information following this POST; 05/23/2013. This is for discussion and rationalization given present guidance.)

1.)  Create the very first visit  post July 1 to be a progress reporting period. The present guidance allows you to report progress EARLIER than every 10 days. Essentially any treatment after July 1 would become the first day of my next day 10 episode of care.   You then record the present status and goal for the particular function you are seeing the patient for, even though you may not have already transferred any evaluation information to CMS. Evaluation information should be in my written chart, however if audited; it was due for all services post January 1.  The discipline, G code and impairment modifier are placed to the bill with the appropriate billable CPT code when I make this first visit post July 1st as a ‘progress report’.

2.) I re-evaluate the patient (if they meet conditions of Medicare Re-evaluation) on the first date of service in July. I then state the Initial, and goal G code & modifier along with the appropriate CPT code for that care. 

3.) If it is the last treatment within the episode of care and it occurs on any day after July 1st (only 1 date of service) then I report the previously charted goal  as a G  code & modifier along with the discharge G code and modifier. The chart should have the initial, and any progress up to that point available on the chart for audit if the chart is requested for any ADR (additional development request). 

These are the scenarios I see as far as billing possibilities given the MM8005 change release notice and if I had not practiced sending any billing codes through to my Medicare Audit Contractor. (FI/MAC)  No one should be procrastinating now, we’re in the final lap – “Get ‘Er Done”!

If given the benefit of a doubt you have not covered yourself to follow this first release specifically as written, I fear the Medicare Trust Fund may have gathered anywhere up to another six month buffer of therapy care on audited records. And finally on pg. 2 of MM8005 they promise this in a highlighted note: “A separate CR (and related MLN Matters® Article) will be issued regarding the editing required for claims with therapy services on and after July 1, 2013, at which time Medicare will begin returning and rejecting claims, as applicable, that do not contain the required functional G-code/modifier information.” Sit tight, this has to occur any day now!  I have contacted CMS employees, Pam West and Simone Dennis restating the concerns our clients have voiced, as well as list serve discussions and I am confident this instruction is soon forthcoming.

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