The Therapists Guide to Functional Limitation Reporting

April 2013

Whats in a Name?
Functional Limitation Reporting Functional Outcomes Reporting Claims-Based Functional Outcome Reporting (CBOR)

PQRS vs. FLR

Program Detail Start Date Participants (Med Part B)

PQRS
2007 (incentive program) 2015 (penalty program) Eligible professionals (incl. PT, OT, SLP, and DC) billing for outpatient therapy services in private practice settings Facility based outpatient practices are not able to participate Claims Registry Determined by CPT codes submitted (97001and 97002)

Functional Limitation Reporting

January 1, 2013 (effective) July 1, 2013 (mandatory w/penalty) All practice settings that provide outpatient therapy services (PT, OT, and SLP) furnished in all outpatient settings including facilities

Reporting Method Reporting Frequency Information Reported

Claims Determined by visit (initial examination, every 10th (or progress note), re-exam discharge) Functional limitation G-code Severity modifier Therapy modifier (GP, GO, and GN)

Quality Data Code (QDC) GCode QDC Modifier (1P and 8P)

What is a G-Code?
G-codes are QDC codes youll use to describe your patients functional limitationthe primary reason he or she is seeking your therapeutic servicesand submit to CMS on your claim. Effective January 1, 2013, CMS will begin testing the codes for claims-based functional limitation reporting. On July 1, 2013, CMS will require therapists to report these new Gcodes, moving us closer to incorporating function and functional progress within our treatment. You should already be checking (and documenting) functional progress through your short- and long-term goal updates at the initial exam, 10-visit mark minimum (or progress note), and at discharge; now its really just about linking a G-code and modifier with that progress.

More About G-Codes

Here are some of the G-code categories for PTs and OTs:
Mobility: Walking and Moving Around Changing and Maintaining Body Position Carrying, Moving, and Handling Objects Self Care Other PT/OT Primary Functional Limitation Other PT/OT Subsequent Functional Limitation

More About G-Codes

There are also G-code categories specifically for SLPs. These include:
Swallow Motor Speech Spoken Language Comprehension Spoken Language Expression Attention Memory Voice Other SLP

Every Category Has Three Codes

Code
GXXX

Information Communicated
Current functional status

When Reported
Therapy episode outset (initial examination) At minimum at every 10th visit or progress note Formal re-examination (if performed during episode of care) Therapy episode outset (initial examination) At minimum at every 10th visit or progress note Discharge from therapy or to end reporting Discharge from therapy or to end reporting

GXXX

Projected goal functional status

GXXX

Discharge functional status

Mobility G-Code
Lets take a look at the Mobility: Walking and Moving Around G-codes. Just as in each G-code category, there are three codes that you will use to report current status, projected goal status, and discharge, respectively. G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

G-Code Modifiers
In addition to reporting a current (or discharge) status and projected goal status G-code at the initial examination, every 10th visit minimum (at progress note), and at discharge, you must apply a severity/complexity modifier to each code (see table below in a seven point scale). You base this severity/complexity assessment on the score of an outcome measurement tool as well as your skilled clinical knowledge as a therapist. You must also continue to include the therapy modifiers (GO, GP, and GN) to indicate that the therapy services are furnished under an OT, PT, or SLP plan of care, respectively.

At the Initial Examination

Determine current primary functional limitation.
Within the Subjective Section, select the primary functional limitation category Within the Objective Section, select appropriate functional assessment tool(s) or objective measure(s) Then, based on the functional assessment tool(s), determine the severity of limitation and select the corresponding modifier

Determine the projected long-term goal.

Based on the current functional limitation status and other patient information

Find the appropriate G-code and modifier on your billing sheet. It will then pass through the integration to the appropriate billing software.
Current status with severity modifier Projected goal with severity modifier

At Minimum10th Visit (Progress Note)

Determine current primary functional limitation.
Re-administer the functional assessment tool(s) or objective measure(s) Assess the severity of limitation progress

Re-verify the projected goal.

If your patient meets his or her initial primary limitation goal, you must choose a subsequent limitation as the patients new primary limitation (or discharge the patient)

Find the appropriate G-code and modifier on your billing sheet. These will then pass through the integration to the appropriate billing software.
Current status with severity modifier Projected goal with severity modifier

If New Functional Limitation Exists

Discharge initial primary limitation.
Within the Subjective Section, determine and select a new functional limitation category Within the Objective Section, select a new appropriate functional assessment tool(s) or objective measure(s) Then, based on the functional assessment tool(s), determine the severity of this new limitation and select the corresponding modifier

Determine the new projected long-term goal based on the current functional limitation status and other patient information.

Find the appropriate G-code and modifier on your billing sheet. These will then pass through the integration to the appropriate billing software.
Current status with severity modifier Projected goal with severity modifier

New Functional Limitation Note

On this particular note, even though you are selecting a new functional limitation, your note will still display the initial primary limitation discharge information, including the discharge and goal. Determine G-code the new projected log-termThe goal new functional limitation Based on the current functional limitation status and other patient information information will then carry forward to the next progress or discharge note (whichever is appropriate). If you reach the goal of the primary limitation you listed, you must have a subsequent limitation to continue treating the patient. If there is no subsequent limitation, you must discharge this patient.

At Discharge
Re-administer the same functional assessment tool(s) and/or objective measure(s).
Determine the severity of limitation Determine that the patient met the primary functional limitation goal Determine that no other functional limitations are present

Re-verify the projected goal.

Find the appropriate G-code and modifier on your billing sheet. These will then pass through the integration to the appropriate billing software.
Discharge status with severity modifier Projected goal with severity modifier

Patient Example
Patient Will has sought your PT services following a total hip replacement. You establish Wills primary functional limitation as Mobility: Walking and Moving Around. Because this is his initial examination, you select the G-code G8978 (Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals).

Mobility: Walking and Moving Around G-Codes G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

Patient Example, Contd.

Now, for the modifier:
Appropriate to Wills current condition, you select the lower extremity functional scale (LEFS). Will scores a 5, which means he is at 6.25% of maximal functionor 93.75% impairment. This corresponds to the CM modifier. Wills current status G-code at his initial examination is G8978 CM GP.

Patient Example, Contd.

Now, for Wills goal:
You select G-code G8979 (Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting). You assign modifier CI because you believe Will will improve to at least 1% but less than 20% impairment. Wills project goal status G-code at his initial examination is G8979 CI GP.

Mobility: Walking & Moving Around G-Codes G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

Patient Example, Contd.

At the 10th visit minimum or progress note:
Wills current status G-code will remain the same (G8978). However, as a result of your treatment over these last 10 visits, Wills score on the LEFS has improved to 18. This means he is now at 22.5% of maximal functionor 77.5% impairmentwhich corresponds to the CL modifier. Wills current status G-code at his 10th visit is G8978 CL GP; his projected goal status G-code remains the same (G8979 CI GP).

Mobility: Walking & Moving Around G-Codes G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

Patient Example, Contd.

At 20th visit:
Wills progress has been outstanding, and he scores a 75 on LEFS, which means he is at 93.75% of maximal functionor 6.25% impairment. This corresponds to the CI modifier. Because Will has met his primary functional limitation goal, you must determine whether Will will continue with treatment or require discharge. The only way to continue treatment is to identify a new primary limitation. In Wills case, there is no applicable new limitation and thus you discharge him from therapy.

Patient Example, Contd.

At discharge:
Wills current status G-code will change to G8980 (Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting). Because Wills progress has been outstanding, he has met his goal with a score of 75 on LEFS, which means he is at 93.75% of maximal functionor 6.25% impairment. This corresponds to the CI modifier. Wills current status G-code at discharge is G8980 CI GP; his projected goal status G-code remains the same (G8979 CI GP.)
Mobility: Walking & Moving Around G-Codes G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

Patient Example, Contd.

At discharge:
Wills current status G-code will change to G8980 (Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting). Because Wills progress has been outstanding, he has met his goal with a score of 75 on LEFS, which means he is at 93.75% of maximal functionor 6.25% impairment. This corresponds to the CI modifier. Wills current status G-code at discharge is G8980 CI GP; his projected goal status G-code remains the same (G8979 CI GP).
Mobility: Walking & Moving Around G-Codes G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals. G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

If There is a New Limitation

After Will meets his primary functional limitation goal, you select his new primary functional limitation, which in Wills case is wound care (he no longer has any specific functional limitations, however, his wound is not healing well). Because this is the first time you are assessing this limitation, which now becomes primary, you will select the G8990 G-code, Other PT/OT Primary Functional Limitation. Based on your assessment, you decide to perform the South West Regional Wound Care Toolkit.* He is still 50% limited in wound healing capacity so you select the CK modifier. Wills new G-code is G8990 CK GP. Repeat steps for assessment at 10th visit minimum and discharge.
Other PT/OT Primary Functional Limitation G8990: Other physical or occupational primary functional limitation, current status, at therapy episode outset, and at reporting intervals. G8991 Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. G8992 Other physical or occupational primary functional limitation, discharge status at discharge from therapy or to end reporting.
*www.thehealthline.ca.healthlibrary_docs/B.9.2.a.WoundSizeReducInstruc.pdf

Claim Submission
Report FLR G-codes as a separate line item Functional limitation data is comprised of three pieces of info:
G-Code Severity Modifier Therapy Modifier

Non-payable Code
$0.00 Private $0.01 Institutional

Multiple Page Claims

Complete total for item 27 on the last CMS-1500 claim form

Things to Note
You must perform a functional outcome measurement during every assessment (examination, 10th visit minimum/progress note, and discharge) and use the score, along with your own clinical judgment, to select the appropriate modifier. There may be instances where your functional outcome measurement tool provides a score that does not directly correlate to the available modifiers. In this case, you must use your judgment and clinical expertise to make a selection. Make sure you are consistent with all patients. Always restate the projected goal status you implement in your patients long term goal. Should this goal change for any reason, document it. While CMS is not requiring you to implement G-codes until July 1, 2013, they will be available within WebPT early. We highly recommend that you use this time to become familiar with the codes and work to implement them into your workflow before they become mandatory.

Things to Note, Contd.

If your patients functional limitation does not fit into one of the predefined categories, you can use the other category. Dont forget to contact your billing service or billing software vendor to ensure they can properly process the G-codes before they are mandatory in July. CMS is still reviewing unique clinical situations (e.g., examination only, one visit/consultative). We will provide you with this information as it becomes available over the next few months.

Resources
APTA www.apta.org/payment/medicare/codingbilling/functionallimitation/ CMS www.cms.gov/medicare/billing/therapyservices/index.html WebPT www.webpt.com/blog

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