by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 19th, 2015
Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report non-payable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
For the severity modifiers, providers should include a description of how the modifiers were determined.
Functional reporting is required on claims throughout the entire episode of care.
For each non-payable G-code reported, a modifier must be used to report the severity level for that functional limitation.
Functional Reporting is required on therapy claims for certain dates of service (DOS) as described below:
- At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;
- At least once every 10 treatment days on the claim for services on the same DOS that the services related to the progress report are furnished;
- At the DOS that an evaluative or re-evaluative procedure code is submitted on the claim; and
- At the time of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., this may occur when the beneficiary discontinues therapy unexpectedly.
When functional reporting is required on a claim for therapy services, two G-codes will generally be required. Two exceptions exist:
1. Therapy services under more than one therapy POC--Claims may contain more than two non-payable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.
2. One-Time Therapy Visit--When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy, and speech-language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers.
Contractors edit institutional claims to ensure the following:
- that a Gn, GO, or GP modifier is present for all lines reporting revenue code 042X, 043 X, or 044X.
- that no more than one GN, GO, or GP modifier is reported on the same service line.
- that revenue codes and modifiers are reported only in the following combinations:
- that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation).
There are 42 functional G-codes, 14 sets of three codes each. Six of the G-code sets generally describe PT and OT functional limitations, and eight sets of G-codes generally describe SLP functional limitations. For more information click on the link below to see a quick reference chart.