CR8005 implemented a claims-based data collection requirement for outpatient therapy services by requiring reporting with 42 new nonpayable functional G-codes and seven new modifiers on claims for PT, OT, and SLP services. Functional reporting collects data on patient function during the therapy episode of care to understand beneficiary functional limitations and outcomes. This was effective for therapy services with dates of service on or after 1/1/2013 and required the claim to include nonpayable G-codes and modifiers, which describe a beneficiary’s functional limitation and severity level, at specified intervals during the episode of care.
Services that are affected by these reporting requirements: All claims for services furnished under the Medicare Part B outpatient therapy benefit including the PT, OT, and SLP services furnished under the CORF benefit. Functional G-code reporting also applies to the therapy services furnished incident to the service of a physician and certain NPPs, including, as applicable, NPs, CNSs, and PAs.
The providers and practitioners affected by these reporting requirements include 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 also applies to the following practitioners: TPPs, physicians, and NPPs as noted in the above paragraph.
Important definitions you need to understand in reference to Therapy Functional Reporting are listed below for reference:
A reporting episode is defined as the period of time, based upon DOS, from the first reporting of functional codes for the functional limitation being treated by one therapy discipline (PT, OT, or SLP) until the date of discharge (if one occurs) from the therapy episode. Within a reporting episode, there can be multiple reporting periods (definition below).
Reporting Period – covers the same period as progress reporting. A clinician (therapist, physician, or NPP) is required to report once every 10 treatment days.
A reporting period is defined as the period from the first reporting of functional codes until reporting at the 10th treatment day. For subsequent reporting periods, the first visit is the treatment date following the 10th treatment date. Clinicians are permitted to report functional information prior to the 10th treatment day. Please note that a submission of G-codes and modifiers restarts the 10 day count towards the progress reporting period.
Note: A reporting episode links a beneficiary to a specific therapy billing provider NPI. For the purpose of tracking beneficiary’s functional limitations, functional reporting data is reported per beneficiary, per therapy discipline, and per billing provider NPI on specified therapy claims for certain DOS.
Functional reporting, using the G-codes and as described below:
Note: Once one functional limitation is discharged and further therapy is medically necessary, reporting of the subsequent functional limitation begins on the next treatment DOS.
Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy expectantly.
When the beneficiary discontinues therapy expectantly, we encourage clinicians to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:
A reporting episode will be automatically discharged when it has been 60 or more calendar days since the last recorded DOS.
When functional reporting is required at specified intervals for a treatment DOS, generally two G-codes are required. The following exceptions exist:
For claims containing any of the functional G-code(s): the following information must also be included on the claim:
An out of sequence therapy claim has a DOS earlier than the last DOS recorded by the claims processing system. To avoid claims being returned or rejected, we encourage clinicians to submit claims in order by treatment DOS. An out of sequence claim that does not meet the functional reporting requirements outlined above may be returned or rejected and providers will need to resubmit the out of sequence claim, and possibly other claims, to correct the information.
Functional reporting is always required when a HCPCS/CPT evaluation or re-evaluation code is reported on a DOS. These HCPCS/CPT codes are listed below:
Evaluation/Re-evaluation Codes: 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, and 97004.
Clinicians are not required to furnish an evaluative or re-evaluative procedure every time G-codes and modifiers are reported. An evaluation or re-evaluation should be furnished when it is medically necessary and not solely for reporting at the required intervals.
In addition the clinician furnishing the therapy services must report the functional information on the therapy claim, and must also track and document the G-codes and modifiers in the beneficiary’s medical record of therapy services
The self-care G-code set (G8987-G8989) is used below to illustrate the required reporting of functional G-codes and severity modifiers at specified reporting intervals.
See the “Quick Reference Chart” link at the end of this article for a complete list of G-codes and modifiers used in functional reporting in a printable format.
At the outset of the therapy episode of care * | At the end of each progress reporting period ** | At the time of discharge from therapy episode of care *** | |
Self-Care G-Code set (G8987-G8989) | |||
G8987 Current Status + Corresponding Modifier |
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G8988 Goal Status + Corresponding Modifier |
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√ |
√ |
G8989 Discharge Status + Corresponding Modifier |
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A reporting episode is defined as the period of time, based upon DOS, from the first reporting of functional codes for the functional limitation being treated by one therapy discipline (PT, OT, or SLP) until the date of discharge (if one occurs) from the therapy episode. Within a reporting episode, there can be multiple reporting periods (definition below).
Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy expectantly. When the beneficiary discontinues therapy expectantly, we encourage clinicians to include discharge reporting whenever possible on the claim for the final services of the therapy episode