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Functional Reporting

As of January 1, 2019 Medicare no longer requires functional reporting, however, some payers may still require functional reporting.

Beneficiary function information is reported using 42 nonpayable functional G-codes and seven severity/complexity modifiers on claims for PT and OT services. Functional reporting on one functional limitation at a time is required periodically throughout an entire PT, or OT therapy episode of care.

Services Affected

These requirements apply to all claims for services furnished under the Medicare Part B outpatient therapy benefit and the PT and OT services furnished under the CORF benefit. They also apply to the therapy services furnished personally by and incident to the service of a physician or a non-physician practitioner (NPP), including a nurse practitioner (NP), a certified nurse specialist (CNS), or a physician assistant (PA), as applicable.

Providers and Practitioners Affected

The functional reporting requirements apply to the therapy services furnished by the following providers: hospitals, CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (when the beneficiary is not under a home health plan of care). It applies to the following practitioners: physical therapists, occupational therapists, and speech-language pathologists in private practice (TPPs), physicians, and NPPs as noted above. The term “clinician” is applied to these practitioners throughout this manual section.

Function-Related G-codes

There are 42 functional G-codes, 14 sets of three codes each. Six of the G-code sets are generally for PT and OT functional limitations and eight sets of G-codes are for SLP functional limitations. The following G-codes are for functional limitations typically seen in beneficiaries receiving PT or OT services.

The first four of these sets describe categories of functional limitations and the final two sets describe “other” functional limitations, which are to be used for functional limitations not described by one of the four categories.

Mobility G-code Set

G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals Mobility current status

G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Mobility goal status

G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting Mobility D/C status

Changing & Maintaining Body Position G-code Set

G8981 Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals Body pos current status

G8982 Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Body pos goal status

G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting Body pos D/C status

Carrying, Moving & Handling Objects G-code Set

G8984 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals Carry current status

G8985 Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Carry goal status

G8986 Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting Carry D/C status

Self Care G-code Set

G8987 Self care functional limitation, current status, at therapy episode outset and at reporting intervals Self care current status

G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Self care goal status

G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting Self care D/C status

The following “other PT/OT” functional G-codes are used to report:

  • A beneficiary’s functional limitation that is not defined by one of the above four categories;
  • A beneficiary whose therapy services are not intended to treat a functional limitation; or
  • A beneficiary’s functional limitation when an overall, composite or other score from a functional assessment too is used and it does not clearly represent a functional limitation defined by one of the above four code sets.

Other PT/OT Primary G-code Set

G8990 Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals Other PT/OT current status

G8991 Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Other PT/OT goal status

G8992 Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting Other PT/OT D/C status

Other PT/OT Subsequent G-code Set

G8993 Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals Sub PT/OT current status

G8994 Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting Sub PT/OT goal status

G8995 Other physical or occupational subsequent functional limitation, discharge from therapy or end reporting. Sub PT/OT D/C status

Selecting the G-codes to use in Functional Reporting

Only one functional limitation shall be reported at a time. Consequently, the clinician must select the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment. When the beneficiary has more than one functional limitation, the clinician may need to make a determination as to which functional limitation is primary. In these cases, the clinician may choose the functional limitation that is:

  • Most clinically relevant to a successful outcome for the beneficiary;
  • The one that would yield the quickest and/or greatest functional progress; or
  • The one that is the greatest priority for the beneficiary.

In all cases, this primary functional limitation should reflect the predominant limitation that the furnished therapy services are intended to address.

For services typically reported as PT or OT, the clinician reports one of the “Other PT/OT” functional G-codes sets to report when one of the four PT/OT categorical code sets does not describe the beneficiary’s functional limitation, as follows:

  • A beneficiary’s functional limitation that is not defined by one of the four categories;
  • A beneficiary whose therapy services are not intended to treat a functional limitation; or
  • A beneficiary’s functional limitation where an overall, composite, or other score from a functional assessment tool is used and does not clearly represent a functional limitation defined by one of the above four categorical PT/OT code sets.

Choosing the Correct Severity/Complexity Modifiers

Each G-code requires one of the following severity modifiers. When the clinician reports any of the following a modifier is used to convey the severity of the functional limitation: current status, the goal status and the discharge status.

Modifier

Impairment Limitation Restriction

CH

0 percent impaired, limited or restricted

CI

At least 1 percent but less than 20 percent impaired, limited or restricted

CJ

At least 20 percent but less than 40 percent impaired, limited or restricted

CK

At least 40 percent but less than 60 percent impaired, limited or restricted

CL

At least 60 percent but less than 80 percent impaired, limited or restricted

CM

At least 80 percent but less than 100 percent impaired, limited or restricted

CN

100 percent impaired, limited or restricted


The severity modifier reflects the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge. In selecting the severity modifier, the clinician:

    • Uses the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument, as appropriate.
    • Uses his/her clinical judgment to combine the results of multiple measurement tools used during the evaluative process to inform clinical decision making to determine a functional limitation percentage.
    • Uses his/her clinical judgment in the assignment of the appropriate modifier.
    • Uses the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation.

Required Reporting of Functional G-codes and Severity Modifiers

The functional G-codes and severity modifiers listed above are used in the required reporting on therapy claims at certain specified points during therapy episodes of care. Claims containing these functional G-codes must also contain another billable and separately payable (non-bundled) service. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC). Functional reporting using the G-codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims:

    • At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service);
    • At least once every 10 treatment days, which corresponds with the progress reporting period;
    • When an evaluative procedure, including a re-evaluative one, ( HCPCS/CPT codes 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97161, 97162 ,97163, 97164, 97165, 97166, 97167, 97168) is furnished and billed;
    • At the time of discharge from the therapy episode of care–(i.e., on the date services related to the discharge [progress] report are furnished); and
    • At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is necessary.
    • At the time reporting is begun for a new or different functional limitation within the same episode of care (i.e., after the reporting of the prior functional limitation is ended)

Functional reporting is required on claims throughout the entire episode of care. When the beneficiary has reached his or her goal or progress has been maximized on the initially selected functional limitation, but the need for treatment continues, reporting is required for a second functional limitation using another set of G-codes. In these situations two or more functional limitations will be reported for a beneficiary during the therapy episode of care. Thus, reporting on more than one functional limitation may be required for some beneficiaries but not simultaneously.

Citation

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services

Medicare Benefit Policy Manual Ch. 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage


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