Therapy Billing Webinar Follow Up

on Tuesday, 09 April 2013. All News Items | Outpatient Services | Billing

On February 26, 2013, MMP, Inc. presented a webinar on Challenges for Rehabilitation Therapy Medicare Billing in 2013. The main focus of the webinar was the new functional limitation reporting requirements for outpatient rehabilitation therapy services. As a reminder, Medicare requires outpatient therapy providers to report patients’ functional limitation using 42 new non-payable G-codes and the degree of limitation using seven severity/complexity modifiers. This reporting is required at the start of therapy, every ten treatment days, and at the conclusion of treatment for a functional limitation. The requirement was effective January 1, 2013, but Medicare is allowing a six-month testing period. Claims with dates of services on or before June 30, 2013 will be accepted and processed without the required reporting; therapy claims with dates of services on or after July 1, 2013 will be returned or rejected when they do not comply with the reporting requirements.

We hope everyone is making progress on developing processes and procedures to handle the new requirements. As promised, here are the questions received from the webinar and our responses. Please let us know if you have any additional questions.


Questions and Answers:

  1. Is the functional limitation reporting required by any other payers, such as Medicaid, Medicare Advantage (MA) plans, or commercial insurers?
    No. I have seen no information from other payers that indicates they will require the functional reporting. In fact, an FAQ document on the Palmetto GBA website, specifically states that functional reporting is not required for MA plans. You may want to check with specific insurers to verify their requirements.
  2. Will other payers accept the new G codes on claims or will this cause processing problems?
    We recommend that you contact individual payers to pose this question or submit a test claim with the codes to see if it processes correctly.
  3. When does the functional limitation reporting start? Will there be a delay?
    The functional limitation reporting was effective January 1, 2013, but Medicare is allowing a six month testing period. Claims for dates of service on and after July 1, 2013 require the functional limitation reporting. There has been no indication at this time that Medicare will delay these requirements further.
  4. If a patient has a second limitation that requires continuing therapy after therapy for the first limitation is complete, when does reporting on the second limitation begin?
    Reporting on a second limitation begins on the next therapy visit after the visit with the final reporting (“discharge” reporting) for the first limitation.
  5. Is there any payment for the new reporting G codes?
    No. The 42 G-codes for functional reporting are not separately payable.
  6. What are providers to do about discharge reporting if the patient just stops coming for therapy services?
    If the patient simply stops coming to therapy, the provider will not be able to report the discharge G codes. Medicare requires there be another separately payable procedure on the claim with the reporting HCPCS codes which would not be possible if the patient did not show for treatment.
  7. Can therapy assistants select G codes and modifiers for reporting?
    No. G codes and modifiers are selected using the clinician’s clinical judgment. This clinical judgment is reserved for therapists.
  8. Does functional reporting apply to Medicare Secondary Payer (MSP) claims?
    Yes, the functional reporting of G-codes and severity modifiers applies when Medicare is both the primary and secondary payer. (Note: this answer is from a FAQ article on Palmetto GBA Jurisdiction 1 website.)
  9. 9. Should a therapy re-evaluation (CPT codes 97002 or 97004) be charged every 10th visit when the therapist re-assesses the patient?
    No. According to Medicare regulations, are-evaluation is separately payable and 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 plan of care. Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.
Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it. .




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