Medicare Functional Limitation Requirements
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