Medicare Therapy Services Require Level III Codes/Modifiers in 2013

If you report outpatient therapy services for Medicare patients, get ready for a change. Beginning Jan. 1, claims filed at specified points during treatment must include a G code to describe certain functional limitations the patient may have, as well as a modifier to describe the extent of that limitation.

There are now 40 HCPCS Level III G codes (G8978-G9176) to report the status of a Medicare patient’s functional limitation, as related to mobility, self-care, spoken language comprehension, and more (e.g., G8981-G8983 Changing and maintaining body position functional limitation…). These G codes are non-paying, with a status indicator of Q Therapy functional information code, used for required reporting purposes only, and will apply to all services furnished:

• Under the Medicare Part B outpatient therapy benefit

• Under the PT, OT, and SLP services furnished under the Comprehensive Outpatient Rehabilitation Facility (CORF) benefit.

• Incident to the service of a physician and certain Non-Physician Practitioners (NPPs), including, as applicable, Nurse Practitioners (NPs), Certified Nurse Specialists (CNSs), and Physician Assistants (PAs)

When reporting a functional limitation G code, you also must append a modifier to describe the severity and/or complexity of the functional limitation, as determined by the therapist, physician, or NPP providing the service.

• 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

You must report the G-codes and modifiers for services at specified intervals:

• At the outset of a therapy episode of care

• At least once every ten treatment days

• On the same date of service (DOS) that an evaluative or re-evaluative procedure is submitted

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

• On the same DOS that the reporting of a particular functional limitation is ended, when further therapy is necessary.

For a complete list of the applicable G codes, modifiers, and reporting requirements, see MLN Matters® Number: MM8005.

5 Responses to “Medicare Therapy Services Require Level III Codes/Modifiers in 2013”

  1. Carol Woodard says:

    Do you have any information about the documentation requirements to support the “G” code selection?

  2. faith bauer says:

    There are no level III HCPCS codes. That level of HCPCS was eliminated with the implementation of HIPAA. The “G” codes are Level II HCPCS codes.

  3. Melissa Jacobs says:

    have u heard anything about rebate for using PQRS codes on 1500 form?

  4. Ava Werstlein says:

    I am showing that G0456 has an SI of T- which is paid under OPPS. When would a provider chose to utilize 97605/06 codes over the G0456 codes (which pay more than twice as much)?

  5. Bridget Case says:

    Ava, I am wondering the same question. Have you received any information?

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