Functional Outcome Measures in Physical Therapy

 

Beginning January 1, 2013 Medicare requires physical therapist begin reporting functional outcomes on their claims submitted for payment. Medicare and other payers are closely scrutinizing claims for all providers.  This is especially true in the documentation of medical necessity for all physical medicine claims.  The significance of using functional outcome measures has been solidified with this new reporting requirement.

 

It is more important than ever before to objectively measure outcomes by specific, standardized measures that are used consistently throughout the episode of care.  Repeated use of the same outcome measure at the initial evaluation, each re-evaluation or progress report, and again at discharge allows a provider to clearly demonstrate the medical necessity of the care provided

 

While the requirement began January 1st, Medicare has provided a transition period from January 1 to June 30 of this year. If you're not properly reporting your outcome measures by July 1, 2013 your claims will be denied.

 

Medicare has introduced this claims-based data collection strategy to assist in reforming the Medicare payment system for outpatient physical therapy. Medicare will use the data received to determine the need for services, the quality of care, and the value of the service received by the beneficiary.

 

Similar to the Physician Quality Reporting System (PQRS), functional outcomes are being reported by including additional codes on service lines of the CMS 1500 form (or the electronic equivalent).  The codes utilized begin with the letter G and are commonly referred to as the “G-codes”.  As in PQRS, these can be billed for $0.00 or $0.01 depending on the limitations of your practice management system.

 

These codes report to Medicare the progress beneficiaries are making towards their goal.  As the initial goals are created, a primary functional limitation is identified, the deficiency measured and the goal established.  For patients where more than one limitation may apply, the provider must make a determination as to the primary functional limitation, as only one can be reported. The therapist may use the limitation that is most clinically relevant to the successful outcome for that patient; the one that would yield the quickest functional progress; or the one that is the greatest priority for the patient. 

 

The limitation selected should reflect the predominant limitation that the therapy service is intended to address. There are six measures for physical therapists

 

       Mobility: Walking & Moving Around (PT/OT)

       Changing & Maintaining Body Position (PT/OT)

       Carrying, Moving & Handling Objects (PT/OT)

       Self Care (PT/OT)

       Other PT/OT Primary Functional Limitation (PT/OT)

        Other PT/OT Subsequent Functional Limitation (PT/OT) 

 

Click here for a printable list of codes and modifiers

 

Each limitation listed has three codes associated with it. The codes represent the reporting of the projected goal, the current status, and the discharge status. The status is further reported using a modifier to indicate severity and complexity.

 

Modifier

Meaning

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.

 

When selecting the modifier to use, it should reflect the score from the assessment tool and/or other measurement instruments. If multiple tools are used during the evaluation process, the clinician must combine the results and use sound clinical judgment to determine the limitation percentage. Therapists will need to document how the modifier was determined at the first selection and follow the same process at each assessment interval

 

Each claim line will indicate the G-code that represents the impairment, a modifier to indicate severity/complexity and a modifier to identify the discipline (i.e. GP = physical therapy, GO = occupational therapy) the date of the service and the billed amount of $0.00 or $0.01.  The application of the KX or 59 modifiers is prohibited.

 

The functional reporting period introduced by Medicare matches the progress reporting requirement. Beginning in 2013, progress reporting is required at the lesser of every 10th visit or every 30 days.  This means that in addition to the initial visit, an updated status is required at every progress report for current and projected goal with their corresponding modifiers.  At discharge the therapist must report the final status of the patient, again with the corresponding modifier.

 

What does this change mean for me?

 

As a provider of outpatient rehabilitation services you must report this information as a condition of payment. This means that your plan of care must contain functional goals related to the disability reported on the claim.  Your goals must be both objective and measurable.

 

Your documentation must contain the raw scores of the outcome assessment tool used to calculate the score, and clinical rationale behind how you arrived at the modifier value. Your documentation must also include the G–code and modifier you will report on your claims to Medicare

 

How do I start?

 

Begin by identifying the functional outcome tools for your practice. There is no one-size-fits-all or single outcome tool that will address all of your patient’s needs. 

 

Train staff and patients on the importance and use of the outcome assessment tools. Make sure the patient understands what is being asked in the assessment, as the medical necessity of their care will be determined by functional changes reported; make sure your staff understands the importance of that time parameter associated with this recording.

 

If you haven’t already, begin now to train your office staff to implement the changes necessary to support the reporting of functional outcomes. The functional measures must be supplied at the lesser of every 10 visits or every 30 days. Staff must understand the progress evaluation and coding requirements and work with your software to make sure that the claim generation works correctly.

 

As with other requirements, establish a review process at the onset to verify and validate the data being reported to Medicare. 

 

If you need further assistance with this initiative or other requirements, please contact us and we’ll be happy to assist you on your road to compliance.

Functional Outcome Measure Codes

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.

 

Healthlink Denies Therapy Services

In July 2011, Healthlink published the “Standard Medical Necessity Review Checklist”.  This utilization management document includes physical therapy services as requiring pre-certification.  Healthlink has indicated this new policy includes therapies and modalities performed by physicians as well as physical therapists. 
 
Recent conversations with Healthlink customer service representative indicate that HL is now enforcing this policy.  Our experience shows that this enforcement is inconsistent and that it may vary group-to-group.  It is our recommendation that as you verify benefits for your patient, you ask if the therapy services require pre-certification. 
 
Cornerstone Medical Management will appeal the services between January 1 and April 1 that have been denied for “failure to obtain precertification for the services rendered”.  Please be advised that this is a new requirement and that changes need to be made within your office to accommodate Healthlink’s new policy enforcement.