Physical therapists who submit Medicare Part B claims without proper functional limitation data, for services provided on or after January 1, 2013, soon will get feedback from the Centers for Medicare and Medicaid Services (CMS) reminding them of the new functional limitation reporting requirements. For claims processed April 1 through June 30, 2013, CMS will send Remittance Advice messages to providers whose claims lack the required data, alerting them to include the applicable G-codes and appropriate severity/complexity modifier on future specified claims.
Providers who bill certain CPT evaluation/reevaluation codes (the affected codes are: 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, and 97004) and fail to submit functional limitation data will receive a remittance advice code of N566. Providers who bill the affected CPT codes and submit functional limitation codes (G8978-G8999, G9158-G9176, and G9186) without a severity modifier (CH-CN) will receive a remittance advice code of N565.
CMS published this information in transmittal RT1196OTN and in a Medicare Learning Network article.
CMS was mandated to collect information on claim forms regarding beneficiaries' function and condition, therapy services furnished, and outcomes achieved on patient function by the Middle Class Tax Relief Act of 2012. As of January 1, 2013, all practice settings that provide outpatient therapy services must include the functional limitation data on the claim form. To ensure a smooth transition, CMS set forth a testing period January 1 to July 1. After July 1, claims submitted without the appropriate G-codes and modifiers will be returned unpaid.
APTA has additional details and resources on these new requirements under its Medicare webpage.