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

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


Other popular CBOR resources:

APTA’s Functional Limitation Reporting 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:


Do you have to use a standardized outcome measure?
Are progress notes required every 10 treatment days or only when the primary measure changes?
Does SLP have a Subsequent Functional Limitation code? Do not see it listed on the chart.
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?
Will these CMS guidelines be adhered to by the non-traditional Medicare plans, i.e. Advantage Plans?
Can speech use NOMs and OT/PT use another tool?
Will there still be monetary caps?
Are G-codes meant to replace other documentation?
Can you resubmit the last visit with a discharge code if you didn’t realize the patient would be discharged?
How can I edit a bill?
Many outcomes measures have ordinal responses which do not convert well to a % impairment.
Therapists write their own functional goals. Will this be an issue as we move to the new G-codes?
Our EMR is CMS certified. Should they be ready for this?
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?
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?
If a patient self-discharges before the 10th visit, what discharge code and modifier would be used?
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?
How would G-codes be used for PT wound care clinics and debridement?
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.
Where do these codes go on the HCFA form (uniform bill – aka:UB)?
How does one document G-codes for patients who are only seen for one visit for a CMC splint or post surgical splint?
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?
What are considered “composite functional tools?”
When billing as a hospital would you bill the goal G-code on each claim?
How would we use a progression from walking with a walker to a cane?
Does coding (G-codes and modifiers) have to be in billing or just in charting documentation?
Can a PTA report on the 10th visit?
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.
Do we really need to write goals, if we are using these tools and scales to justify our care?
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?
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?
Can you explain how you enter the AM-PAC composite score into the other category for PT, OT and SLP?
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?
Does the KX modifier need to be applied on the new G-codes?
Can the DASH be used for the outcome scale?
Does this Final Rule also include inpatient acute hospitals?
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%?
Do you have to complete G coding and C modifiers on patient that have Medicare Part B as secondary?
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?
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?
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...
How to assign a code to patients who require an augmentative communication system?
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?
We frequently evaluate Medicare patients during a single pre-operative visit, which includes…
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?
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?
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?
Is 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?
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.
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?
We do not have SLP so our OT does swallowing assessments. Can OT use the swallowing G-codes G8996, G8997, G8998?
If a patient sees an OT and a PT on the same date of service, can both services use the same G-code?
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.
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?
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.
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.?
Does G-coding have to be submitted the same day of service, or the same day as billing?
Are revenue codes required on the line of service for the non-payable functional G-codes for institutional claims?
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?
Do you know how I would select a G-code in re: diagnosis of incontinence? Any test/measure forms that would provide a modifier?
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...
Are G-ccodes and modifiers required for Medicare replacement plans such as Aetna Medicare?
A neuro patient that was being seen and making progress utilizing the PSFS was initially a CL and goal was set at a CJ…
A patient has met the original goal of a CH for the mobility category as evidence by receiving a 56/56 for the BERG. …
If you discharge the primary and on the next visit pick a secondary it has to be a different category, correct?
When performing a wheelchair evaluation with no plan of care, do we need to add g-codes to the claim
Just wondering what a good workflow would be for observation patients that start out as inpatient, than turn observation?
As a physical therapist in wound care, our question is how to add the modifier appropriately to 8990 “other” code….
Will there be any new standard reports in MediLinks to collect and report this data?
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 g-codes 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?
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.
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?
Can G-codes still be submitted if the hospital account record has been closed?
Can G-codes be submitted if after the end of the month? After 60 days?
Does CMS require us to have a % of discharges with G-codes?
If patient comes in for secondary diagnosis and primary is being discharged, can the new reporting category be the same as the previous?
Should we be using $0.00 or $0.01 for G-Codes?
How do we handle a situation where the patient terminated services prior to re-evaluation of d/c summary? How do you submit G-codes?
When billing g codes for patients that didn’t come in for a while, it was said that we should do discharge codes at the first visit and then the new codes going forward...
Since the 60 day rule is not working, can you use clinical judgment and look at the last date of service notes to determine functional reporting...
What if the patient was seen at another facility for therapy and did not receive a discharge G-code? How would you proceed if they are being seen for a new diagnosis?
What if a PTA completes part of the daily documentation, then the PT completes the remainder of the documentation and completes G-codes - is that ok?
With all of the errors in processing G-codes, what is the best way to get the claims paid? Can we re-submit claims? ...
We are a private PT office, if we have a patient who is not seen for 60 days, but comes back for the same diagnosis, how do we bill?...
As an inpatient rehab unit, we sometimes have Medicare part B patients. Since we are using the FIM instrument on our other patients...
Are PTA's allowed to do G-codes on a D/C visit?
Can you rely solely on clinician discretion and expertise and not use reliable and valid outcome measure?...
How frequent do progress reports need to be done. Is it every 10 visits or is it every 30 days?
I have SLP also reporting to me. Our claims are billed monthly. We have received kickbacks when speech sees the patient for both a speech-language eval...
Can the G-code serve as the long term goal requirement on the POC?
Are we not supposed to report 3 G-codes at a new eval, even if the patient is returning within the 60 day period?
If you set a goal modifier of CK, the patient meets that, can you stay with the same G-code and just change the modifier to CJ?
My question was also regarding how to bill the 97001 with the previous dc codes and then begin reporting on the 2nd visit with new set. Will the count start from the IE forward I assume?
What happens if a PT sees the patient, expecting to see them again, but then the patient doesn't return? Can we go back and apply a G-code for the visit?
For hospital settings, ST Video Swallow evals are done for outpatients (or inpatients) with Radiology department - is this really a diagnostic procedure or do FLR need to be done as with any ST procedure?
Do ATCs who work for Chiropractors and bill PT codes have to use FLR?
What about physician owned WRT FLR tracking?
How ist he DC different for the inpatient episode, for an observation status patient, for example? Should FLR D/C be done in reference ot the last day of therapy, as per status on that date?
Two plans could be occurring at the same time for a patient living at home, such as an OP ST - Video Swallow Eval at our hospital, while the patient may be receiving ST services at an outpatient clinic. How should this be coordinated?
I heard we were to report 3 G-codes for a new script with a PT already on case load along with dc codes, however, i thought we were only allowed to report 1 set of codes per DOS?
We've had several patients that didn't return for discharge, but returned over 60 days later, but our claims were still denied because of no discharge.
If a patient comes in for a one time visit for a splint application, should G-codes be applied?
How do you report when a PT on case load with mobility reporting brings in a 2nd script and this new script becomes the new primary limitation? Do you DC codes of old reporting at eval and then start new reporting on next visit? Or do you have to report 3 G-codes, then on the next visit dc 1st reporting and then at next visit start new reporting?
If the patient reaches the goal level impairment, let's say CJ, yet they did not meet the desired score on the outcome measure used; do we have to discontinue that goal because they made the impairment percentage even though they didn't meet the goal?
Can the DASH score be used with the Quick Dash also?
Occasionally, we have a 'splint only' order. I understand the need for reporting the current, goal and discharge G-code w/modifiers. Is it better to report under the moving, handling, carrying or the other category? Also, any suggestions on which functional assessment tool is best?
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