Notice: All functional limitation data should be submitted on claims with a nominal charge ($0.01), per the most recent Medicare guidance. Several sample resources within this website still reflect original CMS guidance in which claims without a charge ($0.00) were acceptable. We are in the process of updating those resources to reflect the most recent guidance.
As of July 1, 2013, all those billing outpatient therapy services under Medicare Part B must begin or continue submitting functional limitation data (G-codes) for any beneficiary, or claims will be returned unpaid.
- Those providers who have submitted functional limitation data to the Centers for Medicare and Medicaid Services (CMS) prior to July 1 do not need to restart functional limitation reporting on the first date of service on or after July 1. Instead, for those patients only, therapists can wait to submit functional limitation data until the next required reporting interval (eg, at the patient's 10th visit or at discharge).
- However, for beneficiaries whose treatment began prior to July 1, but for whom functional limitation reporting information has not been submitted prior to July 1, therapists must submit data on the first claim with a date of service on or after July 1. In this case, the CMS claims processing system will open a new therapy reporting episode, and start counting to the next 10 treatment dates of service, starting with the first July 1-or-later claim containing the appropriate current and goal status G-codes and corresponding modifiers.
- Moving forward, therapists must submit functional limitation information for any new patients seen on or after July 1.
Once the therapy reporting episode begins, per the 3 scenarios described above, nonpayable G-codes and modifiers must be included on claim forms to capture the beneficiary's functional limitation data 1) at the outset of the therapy episode, 2) no less frequently than every 10th visit, and 3) at discharge.
The therapist's projected goal for functional status at the end of treatment will be reported on the claim form at every designated reporting interval as of July 1. Modifiers will indicate the extent of the severity/complexity of the functional limitation.
CMS was mandated to collect information regarding function and condition, therapy services furnished, and outcomes achieved on patient function on claim forms per the Middle Class Tax Relief Act of 2012. CMS intends to utilize this information in the future to reform payment for outpatient therapy services.
All practice settings that provide outpatient therapy services must include this information on the claim form. Specifically, the policy applies to physical therapy, occupational therapy, and speech-language pathology services furnished in hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities, rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and private offices of therapists, physicians, and nonphysician practitioners.
The Functional Limitation Reporting Toolkit (.pdf) will walk you through the data reporting process.
Related Video: What You Need To Know | Process for Evaluating With G-Codes
View PTNow's list of functional outcome measures identified for the top (highest-volume) conditions in their content areas.
To help clinicians meet requirements, PTnow has prioritized adding functional outcome measures to its website.
CMS Resources: Outpatient Therapy Services
Tests and Measures Resources