Outpatient Therapy Functional Reporting- Now it Counts!

The testing period for the Outpatient Therapy Functional Reporting System implemented by Medicare ended June 30, 2013.

Functional reporting If you missed this deadline to become compliant with this reporting requirement, then it is imperative you educate yourself on this program as soon as possible. 

medicare part bBeginning January 1, 2013, the Functional Reporting applies to any institutions or medical providers that bill for the following:

  • Therapy services furnished under Part B as an outpatient therapy benefit
  • Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services furnished under the Comprehensive Outpatient Rehabilitation Facility (CORF) benefit

outpatient therapy Four service billing scenarios requiring the functional data are:

  • For the DOS that represents the initialization of the therapy episode of care
  • For the DOS range for every progress reporting period (see description below)
  • For the DOS that an evaluative or re-evaluative procedure code is submitted on the claim (see details and list of applicable codes in table below)
  • On the date of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., when the beneficiary discontinues therapy unexpectedly (see guidelines below on patient discharge)

severity/complexity modifiersThe Functional data is to be reported by combing one of the 42 Non-payable G-Codes (Code Ranges are: G8978-G8999, G9158-G9176, and G918) with one of the 7 severity/complexity modifiers.  G-codes are used to report a beneficiary’s functional limitation being treated and note whether the report is on the beneficiary’s current status, projected goal status, or discharge status. The modifiers that are used to indicate the severity/complexity level of the functional limitation being reported are:

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

required with evaluation   Functional Reporting is always required when any HCPCS/CPT evaluation or re-evaluation code from below is reported.  It is not necessary to furnish an evaluative or re-evaluative procedure every time G-codes and modifiers are reported.

Evaluation/Re-evaluation Codes

92506

92597

92607

92608

92610

92611

92612

92614

92616

96105

96125

97001

97002

97003

97004

remittance advice The Medicare Remittance Advice will indicate 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.

therapy episode of careThe goal of the Functional Reporting program is to quantify the effectiveness/ progress of the therapy episode of care through the utilization of theseG-codes and modifiers on a periodic basis throughout the reporting episode. 

reporting episode   A reporting episode consists of the treatment time period for one therapy type (PT, OT or SLP) that begins with the first date of service reported with functional codes and ending upon the applicable discharge date.  Within the reporting episode, the provider of serviceis required to report once every 10 treatment days, thereforemultiple reporting periods are possible.

outpatient therapy Reporting period spans are calculated like this:

Initial: from the first day functional codes are reported through the reporting at the 10th treatment day. Subsequent: from the first treatment day since last reporting through the next 10th treatment day

Example: DOS treatment 1 to DOS treatment 10, then DOS treatment 11 to DOS treatment 20, etc.  (The exception to this rule applies if the provider reports functional information prior to the 10th treatment day; this will restart the 10 day count towards the progress reporting period.)

 outpatient therapy A reporting episode is similar to a therapy episode of care.  A reporting episode will automatically be discharged if no service is recorded for 60 or more calendar days. A reporting period covers the same period as progress reporting.

discharge reporting Discharge reporting is required at the end of the reporting episode or to signify end of the reporting on one functional limitation prior to reporting on a new functional limitation.

 discontinues therapy In cases where the beneficiary discontinues therapy:

  • with notice, there is an exception to the discharge rule. In these instances, providers should still always attempt to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
  • without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:

  outpatient therapy the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes” subsection; or

outpatient therapy 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.

Medicare FAQ'sFor answers to your questions: