Will it ever stop? The problems with functional limitation reporting claim rejections that is. Grant it, there are some confusing scenarios that create provider side problems in coding, but the bigger issue is the continued problems with CMS and the Medicare Administrative Contractors adjudicating claims. Because of the difference in reporting and adjudication for those reporting on the UB04 claim form and those reporting on the CMS 1500 claim form, as well as the soft-coded edits done by MACs and the hard corded edits in the CMS common working file (CWF) things are a mess. There is simply no other way to put it. All this for a system that has nothing to do with coding for reimbursement, and as most providers understand, will not ultimately give much accurate information on beneficiary functional outcome, the sunk costs on this endeavor for providers is tremendous. (We’ll save discussion on outcomes for another post).
So what is happening with functional limitation reporting claim rejections? If you listen to the folks on the CMS provider customer service lines, it’s nothing that can’t be solved with a review of MM8005, and a refresher on SE1307. That’s what providers have been told for weeks, many couldn’t even get their problem escalated to discuss the issue, even after declaring that they had memorized every word of MM8005. Well as it turns out, CMS had some problems in the common working file with adjudication of claims, and therefore claims were rejecting inappropriately. (Please let me know if this has taken you by surprise).
Functional Limitation Claims Rejections – What to Do Now
Many of the MACs are now reporting on the party line that CMS has detected problems in the common working file that is causing rejections. However, the MACs are also pointing out that there are good rejections (provider fault) and these unfortunate rejections (glitch in the common working file). So now providers are instructed to review their claims and see if they have caused the problems, prior to calling customer services. I guess the rationale in that is why waste anyone’s time, however, most MACs have not provided education and guidance on this, other than direct providers to MM8005 and SE 1307 (Sorry, I don’t mean to keep mentioning these two memos). Kudos to WPS for having conducted a great webinar for their MAC Part A providers.
CMS notes two issues:
Issue 1 – Certain Initial therapy services are rejecting incorrectly indicating the provider did not submit the patient’s functional current status and the paired functional goal status G-code/severity modifier. Issue 2 – Claims are rejecting when a claim is submitted with a different functional G-code set than is currently indicated in the patient’s HIMR history. The example given is when the patient has not been discharged and both sets of functional reporting have the same billing provider NPI and same discipline (GN, GO, or GP modifier). The system is not recognizing an episode of care when 60 days have lapsed since the last billed date of service for the initial G-code set. Therefore, the initial episode of care is not closing which prevents the second episode of care from being recognized.
The error notices associated with these two issues are:
CO-4 – The procedure code is inconsistent with the modifier used or a required modifier is missing
N572 – This procedure is not payable unless non-payable reporting codes and appropriate are submitted
Per an update from Palmetto GBA, CMS has indicated a fix will be placed into production on March 24, 2014, and should address some of the issues associated with the above error codes. Palmetto GBA suggests that providers in their MAC sign up for a CPIL alert for this issue which means you will receive an email when more information is available. Other MACs including NGS and FCSO have reported the same issue. Please stay on alert for notices on this matter from your MAC.
Before contacting the Provider Contact Center, (per the Palmetto update) providers should review requirements for reporting therapy functional G-codes and modifiers. As a failure to meet any one of the requirements below would mean that the rejection was correct and providers will be required to correct and resubmit these claims:
Therapy functional reporting is required at specific intervals. This includes the appropriate non-payable G-codes and associated modifiers.
- At the onset of the therapy episode of care
- Specific points during treatment the treatment at specific points – Once every 10 treatment days – When an evaluative/re-evaluative service is billed (CPT code 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, or 97004)
- At the time of discharge from the plan of care
- Generally, two G-codes will be reported at a time
- One G-code for current functional status and a second G-code for projected goal status
- Reporting G-code out of sequence may result in subsequent services being rejected
- At the end of the reporting period the projected goal status and the discharge G-code both should be submitted
- Only one functional limitation should be reported at a given time. For patients with more than one plan of care, report on the second functional limitation using a different set of G-codes after the first reported functional limitation is complete.
- One of the required therapy modifiers GN – service delivered under an Outpatient Speech-Language Pathology Plan of Care, GO – service delivered under an Outpatient Occupational Therapy Plan of Care, or GP – service delivered under an Outpatient Physical Therapy Plan of Care must also be submitted
- For each non-payable G-code, a severity/complexity modifier must be billed to report the patient’s functional limitation/impairment
Are you having problems with functional limitation reporting claim rejections? Are your claims rejected due to the errors noted above?
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