If you missed this deadline to become compliant with this reporting
requirement, then it is imperative you educate yourself on this program
as soon as possible.
Beginning
January 1, 2013, the Functional Reporting applies to any institutions
or medical providers that bill for the following:- Therapy services furnished under Part B as an outpatient therapy benefit
- Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services furnished under the Comprehensive Outpatient Rehabilitation Facility (CORF) benefit
Four service billing scenarios requiring the functional data are:- For the DOS that represents the initialization of the therapy episode of care
- For the DOS range for every progress reporting period (see description below)
- For the DOS that an evaluative or re-evaluative procedure code is submitted on the claim (see details and list of applicable codes in table below)
- On the date of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., when the beneficiary discontinues therapy unexpectedly (see guidelines below on patient discharge)
The
Functional data is to be reported by combing one of the 42 Non-payable
G-Codes (Code Ranges are: G8978-G8999, G9158-G9176, and G918) with one
of the 7 severity/complexity modifiers. G-codes are used to report a
beneficiary’s functional limitation being treated and note whether the
report is on the beneficiary’s current status, projected goal status, or
discharge status. The modifiers that are used to indicate the
severity/complexity level of the functional limitation being reported
are:
Modifier
|
Impairment Limitation Restriction
|
CH
|
0 percent impaired, limited or restricted
|
CI
|
At least 1 percent but less than 20 percent impaired, limited or restricted
|
CJ
|
At least 20 percent but less than 40 percent impaired, limited or restricted
|
CK
|
At least 40 percent but less than 60 percent impaired, limited or restricted
|
CL
|
At least 60 percent but less than 80 percent impaired, limited or restricted
|
CM
|
At least 80 percent but less than 100 percent impaired, limited or restricted
|
CN
|
100 percent impaired, limited or restricted
|
Functional Reporting is always required when any HCPCS/CPT evaluation
or re-evaluation code from below is reported. It is not necessary to
furnish an evaluative or re-evaluative procedure every time G-codes and
modifiers are reported.
Evaluation/Re-evaluation Codes
| ||||
92506
|
92597
|
92607
|
92608
|
92610
|
92611
|
92612
|
92614
|
92616
|
96105
|
96125
|
97001
|
97002
|
97003
|
97004
|
The
Medicare Remittance Advice will indicate a Claim Adjustment Reason Code
246 (This non-payable code is for required reporting only.) and a Group
Code of CO (Contractual Obligation) assigning financial liability to
the provider.
The goal of the Functional Reporting program is to quantify the effectiveness/ progress of the therapy episode of care through the utilization of theseG-codes and modifiers on a periodic basis throughout the reporting episode.
A reporting episode
consists of the treatment time period for one therapy type (PT, OT or
SLP) that begins with the first date of service reported with functional
codes and ending upon the applicable discharge date. Within the
reporting episode, the provider of serviceis required to report once
every 10 treatment days, thereforemultiple reporting periods are possible. Reporting period spans are calculated like this:Initial: from the first day functional codes are reported through the reporting at the 10th treatment day. Subsequent: from the first treatment day since last reporting through the next 10th treatment day
Example: DOS treatment 1 to DOS treatment 10, then DOS treatment 11 to DOS treatment 20, etc. (The exception to this rule applies if the provider reports functional information prior to the 10th treatment day; this will restart the 10 day count towards the progress reporting period.)
A reporting episode is similar to a therapy episode of care. A reporting episode will automatically be discharged if no service is recorded for 60 or more calendar days. A reporting period covers the same period as progress reporting.
Discharge reporting
is required at the end of the reporting episode or to signify end of
the reporting on one functional limitation prior to reporting on a new
functional limitation.
In cases where the beneficiary discontinues therapy:- with notice, there is an exception to the discharge rule. In these instances, providers should still always attempt to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
- without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:
the same functional limitation, the
clinician must resume reporting following the reporting requirements
outlined in the “Required Reporting of Functional Codes” subsection; or a different functional limitation, the
clinician must discharge the functional limitation that was previously
reported and begin reporting on a different functional limitation at the
next treatment DOS.
For answers to your questions:- locate your Medicare contractor toll-free number
- view MLN Matters®SE1307
- Access the Functional Reporting FAQ document
- Visit Therapy Services page on the CMS website.
A
physician’s reputation in both the community and with their peers can
be influenced by their approach to patient invoicing. See how you can
adopt simple strategies to ensure your patient’s trust and understanding
of the components of their financial responsibilities.
When
I walk into a “free-standing” physician’s office, I expect a bill from
the provider I “see” for the service rendered. When being provided
medical services in an outpatient facility, as a hospital outpatient, or
inpatient, things can be a lot less clear. Medical services can be
performed by “unseen” professionals: anesthesiologists, radiologists,
pathologists, etc. There is typically a facility charge in addition to
the professional charge. Patients do not always put this together, and
it is important if you are scheduling the services to give a detailed
explanation of who will be billing for the services rendered. This
helps to keep your patient from being surprised when the bills start
coming in and prevents those dreaded accusatory phone calls.
We
are all human and can make mistakes. These mistakes can go both ways
by billing services that did not occur or by missing some that did.
Even our EHR software with automated charge capture capability, since
used by fallible humans, can contain honest errors. Internally audit
all charges before they are submitted to the payer for accuracy and
proper medical documentation. You will never have to “defend” your
claims to the insurance company and will be completely confident when
any questions arise from the patient about “if” the services were truly
provided.
Utilize medical billing software, such as 
A
typical healthy person utilizes very little of their insurance benefits
and has little experience deciphering a medical bill, so they may
require additional assistance from your staff. Insure you have
available someone that has full access to the details of the account and
a thorough understanding of the services rendered so that any questions
from your patient can be answered promptly, correctly and with patience
and compassion. Your ideal contact person should be able to turn the
complicated terminology and processes of billing into a something an
everyday person can understand. This is the drawback to utilizing an
“outsourced” type call center, those persons are typically ill-equipped
to answer anything more that the most general of inquiries.
If
you have a physically well patient, don’t leave unnecessary scars over
billing issues. They may be satisfied with their medical care, but an
unsavory experience regarding their bill can prevent future referrals
from that patient or even other physicians if your office gets a
reputation for bad billing practices. Not to mention, one call from a
patient to a payer can send up that red flag that triggers an audit.
Studies
have shown cataracts to be the leading cause of blindness worldwide,
and the leading cause of vision loss in the United States.
CMS Cataract Removal Policy: 
Tobacco
use related diseases cause over 392,000 U.S. deaths per year, in
addition, 50,000 people die from exposure to secondhand smoke. 
Beginning
in January 2006, Medicare’s prescription drug benefit covers smoking
and tobacco use cessation agents prescribed by a physician.
The definitions of cessation counseling attempt and session are listed below:
The procedure codes that represent these sessions are:
The
reimbursement for these procedures ranges from approximately $14.00 to
$29.00 based upon the Medicare locality. Your practice can also receive
additional financial incentives by participating in the Physician Quality Reporting System (PQRS). Core Measure PQRS# 226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.
Valuable information to assist your patient to quit smoking can be found on the 
The “global period” has 7 unique designations that are related to the specific surgical service performed and are indicated on the 
Calculate the global period by counting the day of surgery and 10 subsequent days to equal 
Each FI/MAC sets its own rules.
Used for codes that are typically referred to as an “add-on” code that is always billed with another service.