Last Modified: 3/19/2018 Location: FL, PR, USVI Business: Part A, Part B
Outpatient therapy billing and functional reporting scenarios
The following scenarios resulted from questions on outpatient therapy billing and functional reporting G-codes. Each scenario is followed by the appropriate response with the reference source. For additional information on outpatient therapy and functional reporting, please refer to the Rehabilitation Services for Part B or Rehabilitation Services for Part A page on our Medicare provider website. Finally refer to the Functional Reporting: PT, OT, and SLP Services Frequently Asked Questions on the Centers for Medicare & Medicaid Services (CMS) website for additional guidance.
Scenario 1: How do we report functional G-codes when a patient is being treated for two separate body parts?
Therapists should identify and report on the primary functional limitation G-code that most closely relates to the primary functional limitation being treated or the functional limitation that is the primary reason for treatment. When the patient has more than one functional limitation, the clinician may need to make a determination as to which functional limitation is primary. In these cases, CMS has provided recommendations for the therapist in determining the primary functional limitation:
• The one 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.
In all cases, this primary functional limitation should reflect the predominant limitation that the furnished therapy services are intended to address.
At this time therapists are required to report on only one limitation at a time during the episode of care. Reporting on more than one functional limitation may be required for some patients, but not simultaneously. When treatment continues after the treatment goal is achieved or progress toward the goal is maximized for the primary functional limitation, reporting should be ended on the primary functional limitation. Once reporting on the primary functional limitation is complete, the therapist will begin reporting on a subsequent functional limitation using another set of G-codes. Therapists should identify the subsequent functional limitation using the same guiding principles they used with the primary functional limitation. Reporting will be required for the subsequent functional limitation beginning on the next visit following the submission of the end-of-reporting codes on the primary functional limitation.
Scenario 2: A patient is having physical therapy for one body area and canceled all future visits. The therapist is not able to discharge the patient or report the discharge code for the functional reporting to Medicare. Forty-five days later the patient returns for therapy on a new condition. How do we report the discharge functional code for the first body area and bill for the evaluation for the new condition?
When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded date of service to receive treatment for the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes.” If they return for a different functional limitation, the clinician must discharge the functional limitation that was previously reported on a different functional limitation at the next treatment date of service.
Scenario 3: A patient does not return to be discharged from therapy. They return in two weeks to continue therapy. Should I do another initial evaluation?
When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded date of service to receive treatment for the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes.” If they return for a different functional limitation, the clinician must discharge the functional limitation that was previously reported on a different functional limitation at the next treatment date of service. A re-evaluation is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the original plan of care.
Scenario 4: A patient is currently receiving therapy for one diagnosis and then is referred for therapy by another physician for a different diagnosis. If the patient comes in on the same date for both treatments, although separately documented and billed, how can we account for the eight-minute rule?
If more than one timed Current Procedural Terminology® (CPT®) code is billed during a calendar day, then the total number of units that can be billed is constrained by the total-treatment time. Medicare’s expectation (based on the work values for these CPT® codes) is that a therapist’s direct one-on-one patient contact time will average 15 minutes in length, for each unit. Therapy sessions should not be structured to consistently provide less than an average of 15 minutes treatment for each timed unit. When only one service is provided in a day, providers should not bill for services performed less than eight minutes. For any single-timed CPT® code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to eight minutes through and including 22 minutes.
Source: 11 Part B Billing Scenarios for PTs and OTs and Claims Processing Manual, Publication 100.04, Chapter 5, Section 20.2
Scenario 5: Why might claims with two initial evaluations within 30 days for different diagnoses deny?
If reporting evaluative procedures for multiple plans of care for the same therapy discipline, the clinician should report the evaluative procedure furnished under a separate/different plan of care for a functional limitation that is not subject to reporting as a one-time visit. The clinician would report all three G-codes and corresponding severity modifiers for the functional limitation that most closely matches the evaluative procedure that was furnished.
Scenario 6: Can we append modifier 79 for two therapy evaluations with two different diagnoses? Can we append modifier 59 in this situation?
No. Modifier 79 is appended to an unrelated surgical procedure during a global surgical period. Modifier 59 could be appropriate for therapy purposes only when two medically necessary separate procedures are performed on the same date during distinctly different 15-minute intervals. Documentation must clearly identify that two separate procedures were rendered in order to support billing. In addition, these CPT® codes can be subject to National Correct Coding Initiative (NCCI) edits. It is not appropriate to utilize modifier 59 in order to bypass an NCCI edit.
Source: How to Use the Medicare National Correct Coding Initiative (NCCI) Tools and 11 Part B Billing Scenarios for PTs and OTs
Scenario 7: What is the correct use of Part A condition code G0?
Condition code G0 (zero) should be used for multiple medical visits on the same day with the same revenue code. If there were multiple medical visits on the same day in the same hospital revenue center and those visits were separate and distinct, you must report condition code G0.
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