Medicare Functional Limitation Requirements

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What are the Functional Limitation G- Codes?

Beginning on January 1, 2013 in a testing phase and required as of July 1, 2013, therapists are required to report new G-Codes to report the functional limitation of their patients. This new set of G-Codes will move therapists closer to incorporating function and functional progress with treatments. There are a total of 42 new non-payable G-Codes and 7 new modifiers for use on claims for Physical Therapy, Occupational Therapy, and Speech-Language Pathology services.

**Beginning July 1, 2013, Medicare will begin returning and rejecting claims for therapy services that do not contain the required functional G-Code information.**

 Required Reporting of Functional G-Codes and Severity Modifiers

The functional G-Codes and corresponding severity modifiers are used in the required reporting on specified therapy claims for certain Dates of Service. Only one functional limitation shall be reported at a given time for each related therapy plan of care.

Functional reporting is required on therapy claims as shown below:

  • At the outset of a therapy episode      of care (initial date of service).

  • At least once every 10 treatment      days.

  • The same Date of Service that an      evaluative procedure is submitted (Codes 97001, 97002, 97003, 94004)

  • At the time of discharge from the      therapy episode of care

  • On the same Date of  Service      the reporting of a particular limitation is ended, in cases where the need      for further therapy is needed

 What are the Functional Limitation G-Codes?Below are some of the functional limitation G-Codes that are to be used by Physical Therapists. They are organized in related sets. Please note: this is not a complete list. Mobility Set

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

  • G8979 –      Mobility: walking and moving around functional limitation, projected goal      status, at 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

Changing and Maintaining Body Position Set

  • G8981 – Changing      and Maintaining Body Position functional limitation, current status, at      episode outset and at reporting intervals

  • G8982      - Changing and Maintaining Body Position functional limitation,      projected goal status, at episode outset, at reporting intervals, and at      discharge or to end reporting

  • G8983      - Changing and Maintaining Body Position functional limitation,      discharge status, at discharge or to end reporting

Carrying, Moving and Handling Objects Set

  • G8984 –      Carrying, Moving and Handling Objects functional limitation, current      status, at episode outset and at reporting intervals

  • G8985 –      Carrying, Moving and Handling Objects functional limitation,      projected goal status, at episode outset, at reporting intervals, and at      discharge or to end reporting

  • G8986 –      Carrying, Moving and Handling Objects functional limitation,      discharge status, at discharge or to end reporting.

 Self Care Set

  • G8987 – Self      Care functional limitation, current status, at episode outset and at      reporting intervals

  • G8988 – Self      Care functional limitation, projected goal status, at episode outset,      at reporting intervals, and at discharge or to end reporting

  • G8989 – Self      Care functional limitation, discharge status, at discharge or to end      reporting.

Other PT/OT Primary Set

  • G8990      –      Other PT/OT Primary functional limitation, current status, at episode      outset and at reporting intervals

  • G8991 – Other      PT/OT Primary functional limitation, projected goal status, at      episode outset, at reporting intervals, and at discharge or to end      reporting

  • G8992 – Other      PT/OT Primary functional limitation, discharge status, at discharge      or to end reporting.

 Other PT/OT Subsequent Set

  • G8993 – Other      PT/OT Subsequent functional limitation, current status, at episode outset      and at reporting intervals

  • G8994      - Other      PT/OT Subsequent functional limitation, projected goal status, at      episode outset, at reporting intervals, and at discharge or to end      reporting

  • G8995      - Other PT/OT Subsequent functional limitation, discharge      status, at discharge or to end reporting.

Severity/Complexity ModifiersFor each non-payable G-Code used, a modifier must be used to report the severity/complexity for that functional measure. The severity modifiers reflect the patient’s percentage of functional impairment as determined by the therapist furnishing the therapy services. The seven modifiers include:.

  • CH – 0 %      impaired, limited or restricted

  • CI – At least      1 % but less than 20 % impaired, limited, or restricted

  • CJ – At least      20 % but less than 40 % impaired, limited, or restricted

  • CK – At least      40 % but less than 60 %impaired, limited, or restricted

  • CL – At least      60 % but less than 80 %impaired, limited, or restricted

  • CM – At least      80 %but less than 100 % impaired, limited, or restricted

  • CN – 100 %      impaired, limited, or restricted

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