Functional Limitation Reporting Under Medicare

The Centers for Medicare and Medicaid Services (CMS) was mandated to collect information regarding the beneficiaries function and condition, therapy services furnished, and outcomes achieved on patient function on the claim forms by 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 will apply to physical therapy, occupational therapy, and speech-language-pathology (SLP) services furnished in hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians and nonphysician practitioners.

Under this new rule nonpayable G-codes and modifiers will be included on the claim forms to capture data on the beneficiary's functional limitations:

A. at the outset of the therapy episode;
B. at a minimum every 10th visit; and
C. at discharge.

In addition, the therapist's projected goal for functional status at the end of treatment will be reported on the first claim for services and at the end of the episode. Modifiers will indicate the extent of the severity/complexity of the functional limitation.

The reporting of the functional limitations on the claim form will be implemented on January 1, 2013. To assure smooth transition, CMS sets forth a testing period from January 1, 2013, until July 1, 2013. After July 1, 2013, claims submitted without the appropriate G-codes and modifiers would be returned unpaid.

Request for Clinical Case Examples

If you have a clinical case that you would like to share for posting, please e-mail advocacy@apta.org.

PTNow Resources

To help clinicians meet requirements under the new rule, PTnow has prioritized adding functional outcome measures to its website.

View PTNow's list of functional outcome measures identified for the top (highest-volume) conditions in their content areas.

General Information

• Video: 2013 Reporting Patient Function to Medicare Webinar- 12/17/12
• FAQ: Functional Limitation Reporting General Information
• Chart: Differences Between PQRS vs. Functional Limitation Reporting (.pdf)
• APTA Highlights of the 2013 Physician Fee Schedule Final Rule - 11/2/12 (.pdf)

Documentation Guidelines

• FAQ: Documentation of the Functional Codes
• FAQ: G-Code Claims Submission
• Claim Form Example 1500 (.pdf)
• Clarification of the ICF Categories (.pdf)
• Functional Limitation Reporting: Claims Example: UB-04 (.pdf)
• Reporting G Codes (.pdf)
• Selection of Severity Modifier (.pdf)
• Severity/Complexity Modifiers (.pdf)

Case Scenarios

• Cerebrovascular Accident (CVA) (.pdf)
• Diabetic Foot Ulcer, Functional Limitations (.pdf)
• Diabetic Foot Ulcer, No Limitation (.pdf)
• Low Back Pain (LBP) (.pdf)
• Multiple Sclerosis, Establishing a Maintenance Plan/No Functional Change (.pdf)
• Neck Pain (.pdf)
• One Visit (.pdf)
• Reporting a Primary and Subsequent Limitation (.pdf)
• Skilled Nursing Facility, PT/OT (.pdf)
• Two Plans of Care, Same Facility (.pdf)

CMS Resources: Outpatient Therapy Services

• Medical Learning Network (MLN): Functional Reporting Noncompliance Alerts- 3/20/13
• Transmittal 1196: Functional Reporting Noncompliance Alerts - 3/20/13
• MLN: Implementing the Claims-based Data Collection Requirement - 12/21/12
• Transmitta R2622CP: Implementing the Claims-based Data Collection Requirement - 12/21/12
• Transmittal R165BP: Implementing the Claims-based Data Collection Requirement - 12/21/12
• CMS Physician Fee Schedule Rule (details on pages 221-279) - 11/16/12

Discussion Forum

• Functional Limitation Reporting Under Medicare Discussion Forum

  This discussion forum in APTA Communities is a chance for members to get answers to frequently asked questions and to share experiences.

Tests and Measures Resources

• OPTIMAL
• Online: The Guide to Physical Therapist Practice
• PTNow: Tests and Measures Identified by Section, EDGE, and Other Groups

  APTA section and EDGE workgroups identified functional outcome measures for the top (highest-volume) conditions in their content areas.

• The Rehabilitation Measures Database

  Developed by Rehabilitation Institute of Chicago, Center for Rehabilitation Outcomes Research, Northwestern University Feinberg School of Medicine Department of Medical Social Sciences Informatics group.

• Last Updated: 5/17/2013
• Contact: advocacy@apta.org
• = Members Only