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Medicare G Code Confusion

January 30, 2014 8 Comments

Hum along with me, Big Bird, Grover, Cookie Monster, and the cast of Sesame Street in the Alphabet Song.  Are you humming?  A – B – C – D – E – F – G…………. Ok, stop right there!  education_2008003053-1113int-educationWhich “G” did you mean?  One of 42 functional limitation reporting G codes for PT and OT?  Or perhaps one of the PQRS quality reporting G codes?   Oh, I see, you are thinking unattended electrical stimulation G code.   Wait maybe you were thinking GP, GO, and GN – but stop, those are not technically G- codes, but rather modifiers.  Do you have Medicare G Code Confusion?  Maybe you thought you had if figured out then someone in your clinic asked a question.  Or better yet, a claim got rejected and when you called your Medicare contractor’s customer service line they told you that you had a G-code problem.  Only they didn’t explain it (they read from call scripts) or told you it had something to do with PT, OT or a SLP provider.  Oh dear…..

Medicare G Code Confusion

Let’s start with the easy stuff and progress on up through Medicare G code confusion:

  • G Codes as Level II HCPCS:  G0283 – the HCPCS code used by Medicare (CPT 97014) for unattended electrical stimulation.  There are other G codes, including those that therapists likely use (many in a CORF), however this is one of the top 5 therapy codes billed according to CMS statistics as well as reported in the Physical Therapy Comparative Billing Reports by Safeguard Services.  This code has been around for awhile, and most therapists are familiar with its use for Medicare claims.
  • G Codes for PQRS:  Most codes used by private practice therapists in reporting for the Physician’s Quality Reporting System are G codes.  These codes are used to report a status of a quality initiative (triggered most often in therapy by an evaluation).  There are individual measures and group measures as well as claims-based reporting and registry reporting.  Most private practices are likely using claims-based PQRS reporting (it’s FREE!), and some are may be using registry reporting ($$) via an EMR system or uploading to an independent registry.  However these codes, since they are claims based, often cause problems if not sequenced properly on the CMS1500 claim, particularly on the day of a therapy evaluation when functional limitation reporting G codes (I am getting confused myself!), and may result in a claim denial.  Sometimes this is as a result of an adjudication problem with your Medicare MAC.  PQRS has been around since 2007, so for those participating, even though the quality measures may change from year-to-year, it is basically using “G codes.”
  • G Codes for Functional Limitation Reporting: An interesting and late arrival to therapy in 2013, with a compliance enforcement date of July 1. 2013, they are fraught with problems.  The underlying basis of a loose, non-standardized approach to trying to assess a beneficiary’s functional limitation (only 1, not 2, not 3, not……) and “guess” their outcome, and report on the process every 10 visits in codes pairs.  There are multiple exceptions, and CMS is still adjusting a full 12 months after starting the “trial period” on 1/1/2013.  But it is these G codes that have been the tipping point on claims problems.  WPS has recently reporting on claims problems on the Part A side (hospitals, rehab agencies, CORFs and SNFs) and taking operator error (read that to be either therapist error, billing error) out of the mix, there are CMS “hard” edits on claim adjudication as well as contractor “soft” edits.  Therapists are coming up with multiple patient scenarios that CMS never anticipated, and finding claims rejected due to the adjudication process, which includes claims order sequencing.  We’ll do another post on that whole mess.

Medicare G Code Confusion – More Confusion with Modifiers

Ok, now to add a new wrinkle in the Medicare G code confusion, here are the G modifiers, not to be confused with the G codes.  When the therapy caps were mandated in the Balanced Budget Act of 1997 CMS required all disciplines to enter a modifier indicating therapy type by the GP, GO or GN modifier.  That way on a claim, CMS could distinguish to which therapy cap to assign the billed charges (toward either the PT/SLP cap or the OT cap).  That worked on the CMS 1500 claims, but on the UBo4 claims for institutional providers, the therapy modifier also has to match up the appropriate revenue codes series:  42x for PT, 43X for OT and 44X for SLP.  Here are the therapy discipline modifiers which must be on every claim line (including functional limitation reporting:

  • Physical Therapist – signified by GP
  • Occupational Therapist – signified by GO
  • Speech-Language Pathologist – signified by GN (GN??)

Clearing Up Medicare G Code Confusion – Play Book

What’s a provider to do?  More importantly what is everyone that is involved in this process to do?  Ban the terminology “G code”, call everything by its name, PQRS, FLR, unattended electrical stimulation and therapy discipline modifiers.  Do this when communicating to your billers, the folks that do charge entry, and more importantly those that will be calling your Medicare contractor to ask why a claim was rejected.  Believe me, if you don’t have your “G code” (oops, I thought I just banned that!) playbook straightened out, by the time you are done talking to your MAC’s customer service, you won’t for sure!

What problems have you had with claims and FLR, PQRS in particular?  Do you have questions?  Has your MAC told you to go back and read MM8005? Have you read MM8005 a million times, and nothing in there answers your problems?  Let me know……


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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (8)

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  1. beth says:

    If you work in a SNF and a patient goes into the hospital (an unexpected dc), are we required to report discharge G-codes? There seems to be some confusion as to planned/unplanned discharges. Our software carrier will not prompt for a g-code for unplanned discharges.

    This often happens in the SNF. People go to the hospital or are sick and can’t participate which ends up in a could days without therapy before they go out. So a functional level isn’t really known.
    If we do need to report a level, should it be the last known level?

  2. Nathan says:

    G-codes are required on initial evaluation and on discharge. For those times in between, should we be using the 10th visit or the re-certification/progress eval date?

  3. Hi Nathan – Thank you for your question. Codes for reporting functional limitation are required upon evaluation, reevaluation (when 97002/97004 are used). Additionally they are required every 10th visit at a minimum. As a result of the 10 visit requirement, CMS no longer adhere to the “10 visits or 30 days” requirement for a progress report, instead requiring a progress report at the 10th visit where there is also a requirement to date FLR codes. Recertification may be up to 90 calendar days, and it is likely that a patient would have reached the 10th visit mark prior to the 90 days of a certification period. I hope this answers your question. Reference can be found in Chapter 15 (beginning at Section 220) of the Medicare Benefits Policy Manual.

  4. Beth Finley says:

    Ms. Nancy,
    I’d just like to verify with you that FLR is required by traditional Medicare and many Medicare Advantage plans while PQRS is only required by traditional Medicare. Can you just verify this so that I can advise my clients appropriately. I’d also like to give them a current list of Medicare Advantage plans that require FLR as of 2016. Do you have such a list?

  5. Beth, thank you for your comment. CMS has published much information and FAQ on functional limitation reporting (FLR) and has clarified that it applies to traditional (fee for service) Medicare. Have you referenced the CMS site for PQRS information? There is general information, as well as information that is indexed by year (as the measures change, and requirement for measures also may change.

  6. Ian says:

    Has Medicare done away with 10th visit and now it is just every 30 days? What happens if your patient misses their scheduled re-assessment visit and their next visit isn’t until after the 30 day window?

  7. Hi Ian, and thank you for your question. Medicare requires a progress report every 10th treatment day. The therapist is required to write a progress report for the 10th visit. The “either/or” requirement of 10 treatment visits or 30 days was eliminated effective 1/2013 when the implementation of functional limitation reporting.

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