PTs Rise to 2013 G code Challenge

Follow physical therapy service requirements for new G code and modifier reporting.

By Lynn S. Berry, PT, CPC

Editor’s Note: After this was published, G9157 was replaced by G9186 Motor speech functional limitation, projected goal status at initial therapy.  You will find more information in the Medicare Claims Processing Manual, Chapter 5.

A new, claims-based collections system implemented through the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule calls for adding non-payable G codes with additional severity modifiers on each therapy claim—along with the normal charges and therapy modifiers and applicable Physician Quality Reporting System (PQRS) codes and modifiers.

Rule of Thumb for G Code Use

In the final rule, the Centers for Medicare & Medicaid Services (CMS) instructs us to use G codes and severity modifiers during:

• The initial treatment
• Defined progress periods
• Any subsequent evaluation or re-evaluation
• The end of care (or discharge)
• When reporting of the primary functional limitation has ended with further therapy required
• When reporting begins on a different or subsequent functional limitation

G codes signify the patient’s primary impairment as determined by the therapist. The therapist determines the severity by using a standard set of functional outcome measures denoted by a severity modifier added to the G codes. A G code with a severity modifier is also required for the projected outcome of the patient (the patient’s goal).

The measures for both the goal and the initial level of impairment should be noted in the patient’s plan of care; the goal and current level of impairment should be noted in progress reports no later than every 10 treatment days (a new definition of progress report time frames); and the goal and final level of impairment should be noted in the discharge note or when the goal is reached. For most claims, two G codes are required, with two exceptions:

• When therapy services are under multiple plans of care (physical therapy (PT), occupational therapy (OT), and/or speech-language pathology (SLP)) from the same therapy provider; or
• When it is a one-time visit and all three G codes (current status, goal status, and discharge status) must be reported.

Know Therapy G Codes and Severity Modifier Requirements

To provide an audit trail, the G codes and severity modifiers, their rationale for use, and the pertinent tests provided need to be documented in the medical record. After the primary impairment goal is reached, secondary impairments may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer. The G codes and severity modifiers for PT, OT, and SLP are noted in the final rule (and shown in Table A).

Select only one impairment as primary. If a specific category does not apply, or if using a composite functional measurement tool, select the “other” category. Each impairment category has three applicable codes.

Note: The SLP G codes are aligned with their functional reporting system, the National Outcomes Measurement System (NOMS). For SLP, the “other” category is used for any of the eight remaining NOMS categories not specified in the rule.

Table A: G codes  for 2013

Table B: Severity modifiers for reporting therapy G codes

The severity/complexity modifiers for reporting each functional G code on the claim are shown in Table B.

Here is an example of how to use G codes on a claim:

A 66-year-old patient presents at the clinic and receives a full initial evaluation, including specific impairment and functional measures testing and administration of three PQRS outcome measures: falls, body mass index, and pain level. A plan of care is developed (with specific goals based on the patient’s impairments, co-complexities, and severity) to submit to the physician for certification. Treatment is initiated as specified in the plan. Documentation is completed, and includes all of the tests and measures used and the rationale for the treatment and severity modifier chosen. G codes and modifiers are added to the documentation. The claim is filed for the patient for the date of service with the following entries:

97001 GP X1      $XX.00

97112 GP X1        XX.00

97116 GP X1        XX.00

G8978 GPCL         0.00

G8979 GPCI          0.00

1101F                   0.00

G8731                   0.00

G8417                   0.00

Note: Modifier GP Services delivered under an outpatient physical therapy plan of care (or “other therapy” modifier) must be added to the data codes because they are always therapy codes. The order does not matter when assigning the therapy or severity modifier. Therapy modifiers are not required to be added to PQRS codes. Neither modifier KX Requirements specified in the medical policy have been met nor modifier 59 Distinct procedural service can be used with these G codes. These codes are not only added for 2013, but CMS notes they will continue to require data code submission until a new payment system is developed.

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