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

Mobility: Walking and Moving Around
G8978 Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals
G8979 Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting
Changing and Maintaining Body Position
G8981 Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals
G8982 Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8983 Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting
Carrying, Moving, and Handling Objects
G8984 Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals
G8985 Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8986 Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting
Self Care
G8987 Self care functional limitation, current status, at therapy outset and at reporting intervals
G8988 Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8989 Self care functional limitation, discharge status, at discharge from therapy or to end reporting
Other PT/OT Primary Functional Limitation
G8990 Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals
G8991 Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8992 Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting
Other PT/OT Subsequent Functional Limitation
G8993 Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals
G8994 Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8995 Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting
Swallowing
G8996 Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G8997 Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy
G8998 Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation
Motor Speech
G8999 Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9157 Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
G9158 Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Spoken Language Comprehension
G9159 Spoken language comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9160 Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge
G9161 Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Spoken Language Expression
G9162 Spoken language expression functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9163 Spoken language expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
G9164 Spoken language expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Attention
G9165 Attention functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9166 Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
G9167 Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Memory
G9168 Memory functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9169 Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge
G9170 Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Voice
G9171 Voice functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9172 Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
G9173 Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Other SLP Functional Limitation
G9174 Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
G9175 Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
G9176 Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation

 

Table B: Severity modifiers for reporting therapy G codes

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

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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Lynn Berry, PT, CPC, had over 35 years of clinical and management experience before beginning a new career as a coder and auditor and later becoming a provider representative for a Medicare carrier. She now has her own consulting firm, LSB HealthCare Consultants, LLC, furnishing consulting and education to diverse providers, and is a senior coder and auditor for the Coding Network. Berry has held a variety of offices for her local AAPC chapter and continues as one of the directors of the St. Louis West Chapter.

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One Response to “PTs Rise to 2013 G code Challenge”

  1. Holly Moody says:

    Lynne, this is a really great article. Thanks for taking the time to help me understand. I have to give a presentation on PT tomorrow!

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