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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, June 17, 2013 Posted in: Outpatient Rehab

If you are an institutional provider you shouldn’t see this alert at all – so be ready for G-Codes WITHOUT ALERTS and take this blog as your reminder!

The April 18 release of the CMS Medicare FFS Provider e-News contained  discussions with references to two MedLearn Matter releases pertinent to implementation of claims-based data collection. In that release,Medlearn Matter 8166 provides information on what to expect in the way of alerts when and if you do or do not start practicing transmission of G-codes/modifiers between April 1 and June 30 as a practice run for July 1st; however only non-institutional practices should see those alerts.

They state, “For therapy claims, with dates of service on and after Jan, 1, 2013, processed on and after April 1, 2013, through June 30, 2013, you will receive a Remittance Advice (RA) message to alert you to include the applicable new functional limitation G-codes (from the list of 42) and the appropriate severity/complexity modifier (from the list of 7) on future specified therapy claims”, if in fact you are not yet practicing. Be aware though, these will NOT occur for institutional claims, although institutional providers SHOULD develop workflow to enable this information to populate their uniform bills.

What are the two new remittance advice messages that will alert you? The Claim Adjustment Reason Codes are;  CARC 246 “this non-payable code is for required reporting only” and RARCN565,  “Alert: This non-payable reporting code requires a modifier. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed. When nonpayable HCPCS codes G8978 to G8999, G9158 to G9176 or G9186 are submitted without the appropriate modifier (CH – CN).”

Don’t be alarmed, this is still considered a testing phase whereas “Your carrier or B MAC will continue to process and adjudicate your therapy claims without the required G-codes and severity/complexity modifier,” per the MedLearn Matters discussion.

Recall, Claims-Based Outcomes Reporting (Mediware references as CBOR), is just around the corner. Some facilities/individual providers have taken on the task to prepare and start practicing the workflows required to be in place to acknowledge and permit transmittal; unfortunately up until this time those systems may not have been in place to allow the detail to be sent to the receiving contractor database. Now they seem to be prepared and ready to practice their payer alert messaging.

If you need a refresher on the entire claims-based outcomes guidelines; refer to the Revised Medlearn MattersMM8005.

Fair warning!  Beginning July 1, 2013, all Fee for Service Therapy Claims will be rejected using a NEW RA message when the codes are not present with billing transmittal.  No matter what that code version will be, it translates to zero dollars – so don’t wait.  This process takes a little time for a therapist to learn and it is the therapist that must guide and provide the data.

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