Trouble, trouble I say in River City, that is trouble everywhere you look with functional limitation reporting and unplanned discharges. Not quite the problem that Professor Harold Hill faced, but let’s sing along with a chorus of “76 Trombones”.
In a nice neat world, all patients continue with therapy until their planned discharge, and there is never an issue with an unplanned discharge. Well, in all practicality, we know this happens for a variety of reasons: snow birds heading to Florida, hospitalizations, co-pay affordability and more reasons. If the patient is not discharged from functional limitation reporting by the use of the Discharge Status (and modifier) and Goal Status (and modifier) on the claim, then CMS has their “system” programmed to close the reporting period in 60 days from the last billed visit. However CMS has stated that you cannot report on functional limitations on claims that do not contain billable services. In fact CMS kept reassuring us that this was going to be ok, it was not our fault, we simply could not report, and it would not hold any negative consequences for the provider.
But wait – there is more trouble: the patient returns to therapy within the 60 day timeframe that CMS is keeping the functional limitation reporting period open. The patient has likely decided that they need more therapy, or they have returned from a successful visit to South Beach, or alternatively they have another new diagnosis and another new script for physical therapy. You are headed for trouble, (with a capital “T”) if a claim and you don’t know how and when to report within the 60 day window.
Functional Limitation Reporting Trouble With Unplanned Discharges – Now What Happens?
If the patient returns and continues therapy, or alternatively has a new evaluation with a recommended plan of care then either way functional limitation reporting must begin again. But wait, how to do this when the old episode is less than 60 days ago, and discharge reporting on functional limitations did not occur? Well CMS has indicated that the original functional limitation reporting must be either discharged or continued. What does that mean? If your skilled assessment indicates that functional reporting (based on functional outcome goals that you established in the plan of care) will be in the same category (mobility, for example), then just continue reporting on mobility on the date of the new evaluation (or re-evaluation).
But, you say, the patient is coming with an entirely different diagnosis and your functional reporting must change categories (changing and moving body position). Now what happens? During the new evaluation, if it occurs within the 60 day time frame from the date of the last therapy session with an unplanned discharge, you must discharge the previous functional limitation (mobility). You would report the mobility discharge status and goal status on the date of the new evaluation. Then on the very next visit you would begin reporting on the new functional limitation (changing and moving body position) current status and goal status. Here is how CMS addresses this in SE1307:
When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last 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 reporting and begin reporting on a different functional limitation at the next treatment DOS.
CMS notes that a reporting episode will automatically be discharged when it has been 60 or more calendar days since the last recorded DOS.
How is this working at your clinic? Is you MAC having trouble adjudicating claims – check their list serve announcements, they may be rebilling rejections for G code issues, but they also may be putting you on alert that you will have to rebill. CMS and the MACs acknowledged some problems beginning October 1, 2013 – did you get denials after that related to functional limitation reporting?
How are the G codes working for you (WOW – I just violated my own G code rule!) Let me know.