New Functional Limitation Reporting Requirements Under Medicare Part B

(1)

New Functional

Limitation Reporting

Requirements Under

Medicare Part B

Heather Smith, PT, MPH 1

BACKGROUND AND OVERVIEW

2

(2)

Reform Payment in Therapy Services

1997 BBA • Therapy cap • Call for reformed therapy payment 2006 MEI‐ TRHCA 2007 MMSEA 2008 MIPPA 2010 PPACA 2011 TPTCCA 2012 MCTRJCA • Mandated CMS to collect functional data on beneficiaries 2013 Functional Limitation Reporting Implementation 3

Functional Limitation Reporting

Background

• Middle Class Tax Relief Act of 2012 • CMS was mandated to collect information regarding the beneficiaries on the claim form: • Function and condition • Therapy services furnished • Outcomes achieved on patient function • CMS intends to utilize this information in the future to reform payment for outpatient therapy services 4

(3)

Program Basics: Who

• All practice settings that provide outpatient therapy services: • PT, OT, and SLP services furnished in • hospitals • critical access hospitals • skilled nursing facilities • CORFs • rehabilitation agencies • home health agencies • private offices of therapists, physicians and non‐physician practitioners 5

Program Basics: What

• Therapy service providers will submit nonpayable G‐codes with severity modifiers on their claims for the current status and projected goal • Functional limitation categories include: • Mobility: walking and moving around • Changing and maintaining body position • Carrying, moving and handling objects • Self care • Other

Discipline Specific Category Codes “Other” Codes

PT 4 2

OT 4 2

SLP 7 1

(4)

Program Basics: When

• Functional limitation G‐codes will be submitted for the

primary limitation:

• At the outset of the therapy episode • At a minimum every 10th_visit • At a formal re‐evaluation • At discharge/ end reporting (unless the patient self discharges prior to formal discharge visit)

• A subsequent functional limitation may be reported if

care continues to address the subsequent limitation after

you end reporting of the primary limitation

7

Program Basics: How

• Therapists will use a valid and reliable assessment tool(s) and/or objective measure(s) in determination of the severity of the functional limitation • Multiple tools may be used • Therapist judgment may be used in the severity modifier determination in combination with data gathered • Documentation of the G‐codes and the rationale for selection of severity must be included in the medical record 8

(5)

Reporting Timeline

January 1‐ June 30, 2013

• 6 month testing period for functional limitation data submission

July 1‐ December 31, 2013

• Claims will be returned unpaid if functional information is missing 9

REPORTING DETAILS

10

(6)

Nonpayable G‐codes

• G‐codes are based on the International Classification of

Functioning, Disability and Health (ICF)

• Functional limitation: activity limitations + participation restriction • http://apps.who.int/classifications/icfbrowser/

• Specific categories plus an other category

• Therapist chooses the most appropriate category:

• 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 11

Nonpayable G‐codes

• Choosing “Other”

• Defined by one of the four specific categories • Therapy services are not intended to treat a functional limitation • When an overall, composite or other score from a functional assessment tool (such as FOTO, etc.) is used and it does not clearly represent a functional limitation defined by one of the four code sets.

• “Other PT/OT Subsequent Functional Limitation”

category is only selected after the “Other PT/OT Primary

Functional Limitation” category has been reported on the

beneficiary during the same episode of care.

12

(7)

Nonpayable G‐codes Guide

Code Information Communicated When Reported

GXXX Current functional status •Therapy episode outset (initial evaluation)

•Reporting intervals (every 10th

visit)

•Formal re‐evaluation (if performed during the episode) GXXX Projected goal functional status •Therapy episode outset (initial

evaluation) •Reporting intervals (every 10th visit) •Formal re‐evaluation (if performed during the episode) •Discharge from therapy OR to end reporting

GXXX Discharge functional status •Discharge from therapy OR to end reporting

13

Nonpayable G‐codes CY2013

Mobility: Walking & Moving Around

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

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

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

Changing & Maintaining Body Position

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

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

G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting

(8)

Nonpayable G‐codes CY2013

Carrying, Moving & Handling Objects

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

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

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

Self Care

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

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

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

15

Nonpayable G‐codes CY2013

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

Other PT/ OT Subsequent Functional Limitation

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

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

G8995 Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting

(9)

Severity Modifiers

• 7 point scale • Choosing the modifier: • Reflects the score from a functional assessment tool or other performance measurement instrument. • Combine the results of multiple measurement tools used during the evaluative process • Clinical judgment in the assignment of the appropriate modifier. • CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation 17

Severity Modifiers CY2013

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

(10)

Reporting Frequency

• G‐codes are reported throughout care at specific intervals • Report only on one limitation (primary) • You may report on a second limitation but not simultaneously • If a patient is seen for a second condition beyond the resolution of first then you will report a second (subsequent) limitation 19

Reporting Frequency

• Submission of 2 G codes at each reporting interval except: • Therapy services under more than one therapy POC • One‐time therapy visit. When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider • the clinician reports current status, goal status and discharge status on the claim 20

(11)

Functional Limitation Reporting

Outset (Primary Limitation) ‐Current functional status ‐Projected functional goal Every 10th_Visit ‐Current functional status ‐Projected functional goal Discharge ‐Discharge functional status ‐Projected functional goal End of Reporting (Primary Limitation) ‐Discharge functional status ‐Projected functional goal Reporting of Subsequent ‐Current functional status ‐Projected functional goal Reporting of Subsequent Follow reporting requirements for primary Re‐Evaluation ‐Current functional status ‐Projected functional goal 21

Example of Required Reporting

Mobility: Walking & Moving Around Other Primary No Reporting G8978‐ Current G8979‐ Goal G8980‐ Discharge G8990‐ Current G8991‐ Goal G8992‐ Discharge No code submitted Evaluation/ Beginning of reporting period #1 X X Visits #2‐9 X End of reporting period #1 (10th_visit) X X Reporting period #2 begins (11th_visit) X Visits #12‐13 X Visit #14/ End of reporting on Walking & Moving X X Begin Reporting Period for other primary (15th_visit) X X Visits #16‐19 X End of reporting period #2 (20th_{visit)/ Discharge} X X 22

(12)

Claim Submission

• Functional limitation data is comprised of three pieces of information: • G code • Severity modifier • Therapy modifier • No required order for the modifiers • No KX modifier • Reported as a separate line item • Nonpayable code • $0.01 or $0.00 23

Submission Acknowledgement

• Medicare will return a Claim Adjustment Reason Code 246 (This non‐payable code is for required reporting only.) and a Group Code of CO (Contractual Obligation) assigning financial liability to the provider. • In addition, beneficiaries will be informed via Medicare Summary Notice 36.7 that they are not responsible for any charge amount associated with one of these G‐codes. 24

(13)

Claim Form Example 1500

PQRS Quality Data Codes (QDC’s) Functional limitation data with Therapy modifier and severity modifier (GP & CL/CI) Do not use the KX modifier Both functional limitation and PQRS G‐codes are submitted with either $0.00 or $0.01 charge Both functional limitation and PQRS G‐codes are submitted with either blank unit section or “1” unit attached 25

Claims Example: UB‐04

Functional limitation data with Therapy modifier and severity modifier (GP & CL/CI) Do not use the KX modifier Functional limitation G‐ codes should be submitted with either $0.00 or $0.01 charge Functional limitation G‐ codes are submitted with either blank unit section or “1” unit attached 26

(14)

Reporting

Program Detail PQRS Functional Limitation Reporting Program start date •2007 (incentive program) •2015 (penalty program) •January 1, 2013 •July 1, 2013 (non‐payment) Participants (Medicare Part B) •Eligible professionals (including PT, OT, SLP) billing for outpatient physical therapy services in private practice settings •Facility based outpatient practices are not able to participate •All practice settings that provide outpatient therapy services (PT, OT, and SLP) furnished in all outpatient settings including facilities Reporting method •Claims •Registry •EHR •Claims Reporting frequency •Determined by CPT codes submitted (97001, 97002 , several wound care codes) •Determined by visit (evaluation, every 10th_{, re‐evaluation, discharge)} Information reported •Quality Data Code (QDC) G‐code •QDC modifier (1P, 8P) •Functional limitation G‐code •Therapy modifier •Severity modifier 27

CASE SCENARIOS

28

(15)

Functional Data Requirements

Determine primary functional limitation • Select an appropriate functional assessment tool(s) or objective measure(s) • Determine the category of the primary functional limitation • Determine the severity of limitation Determine the projected goal • Based on the current functional limitation status and other patient information • Determine the projected goal Report the functional limitation data • Current/ discharge status with severity modifier • Projected goal with severity modifier 29

Scenario for Patient with LBP

• 65 y/o male 3 days s/p onset of acute low back pain (LBP)

with (L) LE pain into posterior thigh to knee

• Second episode of this condition in the past 6 mo.

Previous episode had no LE symptoms.

• Injury is not work related

• Comorbidities include hypertension controlled by

medication

• Patient works for painting contractor.

• Has been on bed rest since onset

30

(16)

• The physical therapist chooses the Oswestry

Disability Index for LBP to measure the functional

limitation status for this patient.

• The Oswestry has 10 sections covering areas from pain to

employment.

• It includes questions for activity limitations and

participation restrictions from ICF on which the G‐codes

are based.

Determine Current Functional Status

31

Initial Evaluation Functional

Measurement Data

Test Key findings Score Severity translation Functional limitation category Oswestry Disability Index 35 35% impaired; At least 20 but less than 40% impaired, limited or restricted CJ modifier Mobility: walking & moving around G8978‐CJ 32

(17)

Determine Projected Goal

• Patient reports that his primary goal for PT is to

return to work and prior function.

• He also wants to have the skills to prevent

reoccurrence.

• They agreed upon a goal to return to prior

function.

• The PT then has a goal of 0 on the Oswestry (CH

modifier).

• G8979‐CH

33

Initial Evaluation Functional

Limitation Documentation

Patient reports that his primary goal for PT is to return to work and prior function (G8978) with minimal help. His current impairment level is 20 to 40 percent impaired (CJ) based on his Oswestry score. He is expected to be achieve a score of 0 percent impaired (G8978 CH) after 12 therapy visits. 34

(18)

Initial Evaluation visit

35

10 th

_{Visit Description}

• The patient had been doing well and his Oswestry score

had gone down to 11 his last visit.

• However, he went on a 6 hour car trip over the weekend

and due to the weather he did not get out on a regular

basis to perform his extension exercises.

• He reports he now again has occasional pain down his

thigh.

• The patient’s Oswestry Score is 42 today.

36

(19)

Measurement Data

Test Key findings Score Severity translation Functional limitation category Oswestry Disability Index 42 42% impaired; At least 40 but less than 60% impaired, limited or restricted CK modifier Mobility: walking & moving around G8978‐CK 37

10 th

_{Visit Documentation}

Patient reports that his primary goal for PT is to return to work and prior function (G8978) with minimal help. His current impairment level is 40 to 60 percent impaired (CK) based on his Oswestry score of 42. He is still expected to be achieve a score of 0 percent impaired (G8979 CH) after 12 therapy visits. 38

(20)

10 th

_Visit

39

Discharge Visit Description

• Visit 12

• Patient returns after 2 weeks for review and

progression of his home exercise program and

fitness program. He reports he has been

performing his exercises and positioning

routinely. He is symptom free and has returned

to work without difficulty.

• The patient has reached the projected functional

goal.

40

(21)

Measurement Data

Test Key findings Score Severity translation Functional limitation category Oswestry Disability Index 0 0% impaired, limited or restricted CH modifier Mobility: walking & moving around G8980‐CH 41

Discharge Visit Documentation

Patient reports that he has returned to work and his prior level of function (G8980). His current impairment level is 0 percent impaired (CH) based on his Oswestry score of 0. He has achieved his therapy goals and is 0 percent impaired (G8979 CH) at discharge. 42

(22)

Discharge Visit

43

Summary of Reporting

Initial Evaluation Visit 10th_Visit _{D/C Visit}

G‐code Modifier G‐code Modifier G‐code Modifier

G8978 CJ G8978 CK G8979 CH G8979 CH G8980 CH G8979 CH 44 Mobility: Walking & Moving Around G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting 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}

(23)

Scenario for Patient s/p CVA

• 83 y/o female four week s/p ischemic event of the left

middle cerebral artery resulting in right hemiplegic and

mild aphasia

• Previous therapy includes inpatient rehabilitation

• Co‐morbidity of severe osteoporosis with wrist, hip, and

spinal compression fractures within past year

• Chief complaints include assistance needed to walk short

distance and weakness or right arm

• Reports fatigue with minimal exertion

45

Determine Current Functional

Status

PT Tests and Measures:

• OPTIMAL

• Berg balance test

• 4 meter walk

OT Tests and Measures:

• Disabilities of the Arm,

Shoulder and Hand

(DASH) questionnaire

46

(24)

Measurement Data

Test Key findings Score Severity translation Functional limitation category OPTIMAL Patient identified: •walking outdoors* •climbing up stairs •carrying objects 9 (on primary item*) 70 percent limitation: At least 60 but less than 80% impaired, limited or restricted ‐ CL modifier Mobility: walking & moving around G8978‐CL Berg balance test 29/56 4 meter walk Walks with close supervision and use of cane 4 meter walk at 0.6 m/sec 47

Initial Evaluation Functional

Measurement Data

Test Key findings Score Severity translation

Functional limitation

category DASH Identified issues

with ADL’s 54 54 percent limited: 40 percent limitation: At least 40 but less than 60 %impaired, limited or restricted ‐ CK modifier Self Care: G8987‐CK 48

(25)

Determine the Projected Goal

Physical Therapy

• Prior to CVA lived in

home w husband and

was independent in ADLs

and driving

• Goal is to return to this

setting and prior

activities

• Projected goal is at least 1 percent but less than 20 percent impaired, limited or restricted (CI modifier) • G8979‐CI Occupational Therapy

• Prior to CVA lived in

home w husband and

was independent in ADLs

and driving

• Goal is to return to this

setting and prior

activities

• Projected goal is at least 1 percent but less than 20 percent impaired, limited or restricted (CI modifier) • G8988‐CI 49

Initial Evaluation Functional

Limitation Documentation

Physical Therapy Patient’s primary goal for PT is to be able to walk outdoors with minimal help. Her current impairment level is 70% (G8978 CL) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She is expected to be able to walk outside her home with less than 20% (G8979 CI) impairment after 8 weeks of therapy. Occupational Therapy Patient’s primary goal for OT is to be able to perform ADL’s with minimal help. Her current impairment level is 54% (G8987 CK) based on her DASH score. She is expected to be able to perform her ADL’s with less than 20% (G8988 CI) impairment after 8 weeks of therapy. 50

(26)

Initial Evaluation Visit

51

10 th

_{Visit Description}

• The patient is happy with her progress

• She is able to walk with only close supervision now

demonstrating slightly greater walking speed

• She still notes some decreased confidence walking

outside

• Her balance is improved especially with single limb

stance activities

• Her arm function has also improved and she is able to

dress with minimal difficulty and perform ADL’s more

easily

52

(27)

Measurement Data

Test Key findings Score Severity translation Functional limitation category OPTIMAL Patient identified: •walking outdoors* •climbing up stairs •carrying objects 5 (on primary item*) 40 percent limitation: At least 40 but less than 60 %impaired, limited or restricted ‐ CK modifier Mobility: walking & moving around G8978‐CK Berg balance test 40/56 4 meter walk Walks with close supervision without an assistive devise 4 meter walk at 0.8 m/sec 53

10 th

_{Visit Functional}

Measurement Data

category DASH Some issues with

ADL’s 32 32 percent limited: 40 percent limitation: At least 20 but less than 40 %impaired, limited or restricted ‐ CJ modifier Self Care: G8987‐CJ 54

(28)

10 th

_{Visit Documentation}

Physical Therapy

Patient has improved in safety with her mobility. Her current impairment level for walking around (G8978) is 40% (CK) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She is expected to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy.

Occupational Therapy

Patient is better able to perform her ADL’s. Her current impairment level for ADL’s is 32% (G8987 CJ) based on her DASH score. She is expected to be able to perform her ADL’s with less than 20% (G8988 CI) impairment at time of discharge from occupational therapy. 55

Example of Charge Form for

10 th

_Visit

56

(29)

Discharge Visit Description

• Visit 12 • The patient is much more confident moving around outside • She is able to walk independently at a speed that is appropriate for community participation • Her balance is improved overall and her Berg score indicates she has a low fall risk • She is able to dress independently and perform other ADL’s with minimal difficulty 57

Discharge Visit Functional

Measurement Data

Test Key findings Score Severity translation Functional limitation category OPTIMAL Patient identified: •walking outdoors* •climbing up stairs •carrying objects 3 (on primary item*) 10 percent limitation: At least 1 but less than 20 %impaired, limited or restricted ‐ CI modifier Mobility: walking & moving around G8980‐CI Berg balance test 46/56 4 meter walk Walks independently without an assistive devise 4 meter walk at 1.0 m/sec 58

(30)

Measurement Data

category DASH Mild issues with

ADL’s 16 16 percent limited: 10 percent limitation: At least 1 but less than 20 %impaired, limited or restricted ‐ CI modifier Self Care: G8989‐CI 59

Discharge Visit Documentation

Physical Therapy

Patient has improved in safety with her mobility. Her current impairment level for walking around (G8980) is 10% (CI) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She has achieved her goal to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy.

Occupational Therapy

Patient able to perform her ADL’s with minimal difficulty. Her current impairment level for ADL’s is 16% (G8989 CI) based on her DASH score. She has achieved her goal to perform her ADL’s with less than 20% (G8988 CI) impairment and is discharged from occupational therapy. 60

(31)

Discharge visit

61

Summary of reporting

Provider Initial Evaluation Visit 10th_Visit _{D/C Visit}

G‐code Modifier G‐code Modifier G‐code Modifier PT G8978 CL GP G8978 CK GP

PT G8979 CI GP G8979 CI GP G8979 CI GP

PT G8980 CI GP

OT G8987 CK GO G8987 CK GO

OT G8988 CI GO G8988 CI GO G8988 CI GO

OT G8989 CI GO 62 Mobility: Walking & Moving Around G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting 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 Self Care G8987 Self care functional limitation, current status, at therapy episode outset and at reporting intervals G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting

(32)

Resources

• APTA website • http://www.apta.org/Payment/Medicare/CodingBilling/Function alLimitation/ • Basic program information/ FAQ • Discussion forum • Case studies • Webinar • CMS website • http://www.cms.gov/Medicare/Billing/TherapyServices/index.ht ml 63

Questions

64