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  • CMS to Send Reminders on Functional Limitation Reporting

    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.


    • Do these alerts apply to institutional providers: SNFs that bill part B therapy services?

      Posted by Leslie on 3/27/2013 5:50 PM

    • We are required to bill the functional G-code at the time of a progress report, every 10th visit for 2013. However, a progress report and a re-evaluation have always been different, with a re-evaluation being required/allowed only if there is a change in the patient's status or goals. So, are we required to bill the re-evaluation code every 10th visit to include the G-codes or can the G-codes be reported without an eval/re-eval code?

      Posted by Stephanie on 3/28/2013 10:30 AM

    • A re-evaluation should only be billed for per Medicare requirements and is not a requirement to report G-codes.

      Posted by Daniel Curtis -> >JW[<H on 4/11/2013 2:37 AM

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