Outpatient Therapy Functional Reporting

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:

Reporting Episode - similar to the therapy episode of care

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.

Required Functional Reporting

Functional reporting, using the G-codes and as described below:

• At the outset of the therapy episode of care, i.e. on the DOS for the initial therapy service;
• At every progress reporting period, which occurs at least once every 10 treatment days;
• At the DOS that an evaluative or re-evaluative procedure code is submitted on the claim;
• At the time of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., when the beneficiary discontinues therapy unexpectedly.

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

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:

• the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes” subsection; or
• a different functional limitation, the clinician must discharge the functional limitation that was previously reported and begin reporting on a different functional limitation at the next treatment DOS.

A reporting episode will be automatically discharged when it has been 60 or more calendar days since the last recorded DOS.

Unique Functional Reporting Scenarios 

When functional reporting is required at specified intervals for a treatment DOS, generally two G-codes are required. The following exceptions exist:

1. One-time therapy visit. When a beneficiary is seen for a one-time visit and future therapy services are either not medically indicated or are going to be furnished by a different provider, the clinician reports as a one-time visit. The clinician reports on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.
2. Reporting evaluative procedures for multiple POCs for the same therapy discipline. The clinician should report the evaluative procedure furnished under a separate/different POC for a functional limitation that is not subject to reporting as a one-time visit by reporting all three G-codes and corresponding severity modifiers for the functional limitation that most closely matches the evaluative procedure that was furnished.
   In the above # 2 unique scenario, the DOS that functional codes are reported as a one-time visit alongside separately payable procedure code(s), including evaluative/re-evaluative services, does not count as a treatment day for the progress reporting period of the functional limitation subject to reporting.
3. Therapy services from more than one therapy discipline. Claims will contain more than two nonpayable functional G-codes in cases where a beneficiary receives therapy services on the same treatment DOS from more than one therapy discipline (PT, OT, and/or SLP) from the same therapy provider.

Billing Requirements

For claims containing any of the functional G-code(s):  the following information must also be included on the claim:

• another separately payable (nonbundled) service;
• functional severity modifier in the range CH – CN;
• therapy modifier indicating the discipline of the POC – GP, GO or GN – for PT, OT, and SLP services, respectively;
• date of the corresponding payable service;
• nominal charge, e.g., a penny;
• completion of the units field with “1” unit of service; and
• all other currently required claims data elements as described in the claims processing manuals.

Out of Sequence Claims 

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.

Evaluative Procedures 

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 

Functional Reporting G-codes:

• have a status code indicator of Q = therapy functional information code, used for required reporting purposes only;
• have no payment amounts or relative value units; and
• are “always therapy” codes, which requires the use of a therapy modifier (GP, GO, or GN).

Example of a functional reporting of G-codes:

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.

Reporting Episode - similar to the therapy episode of care *

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.

Discharge Reporting ***

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

Related Content

• MM8005: Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services — Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012
• MM8126 Revised: 2013 Annual Update to the Therapy Code List
  • The above article was issued as an alert to providers and suppliers that these nonpayable G-codes are “always therapy” codes on the therapy list.
• SE1307 - Outpatient Therapy Functional Reporting Requirements
• Quick Reference Chart: Short & Long Descriptors for Therapy Functional Reporting G-codes (580 KB)