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G Code Feedback is in…Let s Review

Written by: Mediware on Monday, March 3, 2014 Posted in: Outpatient Rehab

Explore G-Code Survey Responses

Not long ago, we provided a survey on G-code use in an attempt to gather useful information from providers that they can share with each other on ‘what they have learned’ during this new Medicare mandated, Claims-Based Outcomes Reporting (CBOR).

As promised, now that everyone has had more than a few months to experience the workflow, the lessons learned and the best information on how to avoid a denial; it’s time to circle back to see the responses.

25 Sites Responding:

  • Who Manages G-Codes:  (All that apply – 25 sites have a combination of 48 responses)

Licensed Therapist;  22 –  46%

Licensed Therapist Assistant:   3 –  6%

Support Staff:  9 – 19%

Billing Staff: 14 – 29%

By and large the licensed therapists are not only applying but managing the process within their facilities.

Has the 2 midnight rule pt stay reduced confusion of when to apply the G-Codes to therapy services?

19 Responses:   6 YES  –   13  NO

How many denials has your facility experienced since initiating G-Code modifiers?



  • Admission code not on the final UB when multiple UB’s have been sent for billing.  Contractor believing it should have been.
  • Denied at D/C when only current status and D/C codes on the bill. Rebilled including admission codes.
  • Closing the case if the patient is not seen. Should we or shouldn’t we? CMS states not necessary.
  • Communication breakdown for observation patients still exists. 60 days before CMS closes episode is challenging.
  • Measurement valid tools for musculoskeletal pain when a patient pushes through and ADL skills are accomplished despite pain improvement.
  • Rules for inpatient, observation patients and swing bed patients.
  • Fixing G-code errors after the fact is extremely time consuming for ‘reporting only’ bill updates.
  • Just remembering to code at the right time when not all patients are Medicare.
  • Different documentation systems utilized on inpatient vs. outpatient. When patients are in observation the inpatient system is utilized.
  • Picking correct codes and deciphering the percentages of impairment is confusing given the scale options.

Most Common Denial Reasons Received:

  • Current and goal/goal and discharge were not a PAIRED SET so therefore denied.
  • Inadequate G-code utilization (1 at d/c or all 3 used at discharge and not accepted).
  • Modifiers not printing out on the UB claim when processed.
  • Claim adjustments for unknown reason.
  • Discharge G-codes not present.
  • Forgotten codes – bill already processed.
  • Procedure code inconsistent with modifier utilized/or modifier missing when needed.
  • Denial code 31816 (Return to Provider): You are receiving this reason code when the claim contains any of the following evaluation/re-evaluation therapy codes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004, and the claim is billed without the functional G-code(s) and the appropriate modifier(s).Effective July 1, 2013, outpatient therapy providers are required to report a combination of two non-payable G-codes to show the beneficiary’s functional limitations (i.e., G8979 and G8979). In addition, each G-code must contain the appropriate therapy modifier(s) to indicate Physical/Occupational (PT/OT) or Speech Language (SLP) therapy (i.e., GP, GO, GN), along with the severity modifier (i.e., CJ) to indicate the severity/complexity for that measure.
  • CO119 (Maximum Benefit Reached): CO 119 Benefit maximum for this time period or occurrence has been reached.

Stay tuned for additional information learned at the APTA conference at a Combined Sections session in Las Vegas and for a special guest webinar in April on G-codes.

Have you visited our Clarifications on CBOR and G-codes FAQ yet? It includes more than 75 questions asked by the rehabilitation industry. Check it out, you might get your questions answered!

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