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Claims-Based Outcomes Reporting
CMS will begin accepting Claims-Based Outcomes Reporting (CBOR) with Medicare Part B claim submissions on Jan. 1, 2013 — and will require these G-Codes starting July 1, 2013. The CMS Final Rule can be downloaded here.
These resources can also help you navigate the CBOR requirements with less stress…
You may also want to find out how DocuPRO Rehab Documentation can simplify G-Code requirements.
CBOR Questions & Answers
Do you have to use a standardized outcome measure to convert and can therapists just score/modify based on professional judgment?
Are re-evals required every 10 treatment days or only when the primary measure changes?
Updates to G-codes must be: no less than every 10 treatments days (evaluation counts as day 1), when there is a significant change in condition, when a re-evaluation procedure code is billed, a change in primary condition or upon discharge from care. Here is the list of evaluation codes: 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 97001, 97002, 97003, 97004, 96125.
If using AMPAC, and always selecting other, how is CMS going to be distinguishing if Mobility, Self care, etc.?
On 12/12/2013, CMS clarified that the therapist should apply the scores from composite measures to the appropriate functional G-code if the therapist’s clinical judgement believes that tools can effectively demonstrate a change in the impairment level.
Does SLP have a Subsequent Functional Limitation code?
If the mandatory reporting date is July 1, 2013, does that mean that therapy services provided in June and billed (institutional) in July should have the G-codes and modifiers attached?
CMS is recommending starting data collection very early on. In conversations with CMS, there are no clear plans on how to address the question above; however, CMS did clarify on the 12/12/2013 call that denials should not occur if only the discharge codes appear for patients who were being seen before July 1st, but did not submit status G-codes prior to July 1.
Will these CMS guidelines be adhered to by the non-traditional Medicare plans, i.e. Advantage Plans?
The current regulations only state Medicare Part B.
Can speech use NOMs and OT/PT use another tool?
Yes. PT, OT, and SLP will independently submit their own G-codes and modifiers using either a common or separate measurement instrument(s). There is no requirement to use the same instrument across disciplines. The GN, GO and GP modifiers must be appended to the G-codes to distinguish the disciplines.
Do you know if the standard billing format for hospitals will change to accommodate the addition of the modifiers, etc?
CMS has not published the specific claims processing requirements yet.
Will there still be monetary caps?
So is this meant to replace other documentation?
No. In 2008, CMS updated the manual to include more requirements for functional outcomes reporting. Pub. 100–02, Chapter 15, Section 220.3, Subsection D)http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf They assume everyone is already following these requirements and adding 2-4 additional G-codes on the claim are the only additional burden.
Can you resubmit the last visit with a discharge code if you didn’t realize the patient would be discharged?
CMS has not published the specific claims processing requirements yet.
Many outcomes measures have ordinal responses which do not convert well to a % impairment -- what do I do?
CMS has provided guidance on how to convert scales that have an upper and lower bound; however, many scales do not. It must be assumed that those measures should not be used or you can rely on the ‘therapist judgment’ discussion and let the therapist select the functional impairment modifier directly.
Our EMR is CMS certified. Should they be ready for this?
No. CMS does not certify systems. ONC (Office of the National Coordinator) does. That certification is related to technical specifications for privacy/security, data collection and system interoperability. It is completely independent from CBOR and many other processes governing therapy practice.
What about Neuro patients (Parkinson's for example) where maintenance is just as important as progression in functional goals? How would entering G-codes be impacted?
CBOR is independent from medical necessity and justifications for payment of therapy services. A patient’s reason for therapist must be made as a clinical and business judgment and stand on its own merit. If the patient/therapist decides therapy is reasonable and necessary and services are rendered, you must submit G-codes to get paid. Whether or not the G-codes change will not determine payment.
If a patient self-discharges before the 10th visit, what discharge code and modifier would be used?
You do not have to supply a discharge G-code if the patient self-discharges and you do not have a reasonable estimate of their progress.
If a patient is being seen for two separate diagnoses with two separate functional problems would two G- codes be needed for the initial and goals?
No. Only the primary functional deficit for each discipline treatment of the patient will be reported.
How would G-codes be used for PT wound care clinics and debridement?
There are really two questions here. 1) For treating a non-functional diagnostic category, use the “Other PT/OT Primary Functional Limitation” G-codes. 2) If a patient has no functional impairment, the CH modifier should be applied to the current status, goal, and discharge G-codes.
How does this system work for patients with lymphedema due to breast cancer? These women don't necessarily have functional limitations but are at risk for infection if the lymphedema isn't managed.
Great question. There is currently no ‘carve-outs’ for any patient types. We are still waiting on clarification from CMS.
Where do these codes go on the HCFA form?
CMS has not published the specific claims processing requirements yet.
What about patients who are only seen for one visit for a CMC splint or post surgical splint?
One time visits (i.e.: eval only, splinting, etc), need to code the all three G-codes (status, goal and discharge) in the documentation. This is the only scenario when more than two G-codes should be coded for the same discipline on a single date of service. One good recommendation is to have the patient take the functional assessment before evaluation and then again post-intervention and report the improvement in the discharge G-code functional modifier.
Can you enter more than one primary G code at a time? If not, what is recommended if a patient has multiple deficits that will be treated simultaneously? For example memory and difficulty carrying items.
The primary deficit for each discipline is reported and the GN, GO, GP modifiers must be applied. If OT is seeing the patient for both memory and difficulty carrying items, only the one area of greatest clinical/treatment focus should be reported.
This is not defined within the regulations.
When billing as a hospital, would you bill the goal G-code on each claim?
CMS has not published the specific claims processing requirements yet; however, they have stated claims timelines are independent from when G-codes should be submitted. G-Codes are submitted on evaluation, re-evaluations, progress notes no less than every 10 treatment visits, change in primary condition, material change in current condition and upon discharge. Also, if any of the following procedure codes are billed, G-codes must be on that date of service on the claim: 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 97001, 97002, 97003, 97004.
Additionally for the first claim would you have the eval and goal G-codes on the claim?
Yes, for each discipline treating the patient.
We do not currently use a functional scoring instrument. What do you suggest?
Our therapists write their own functional goals. Will this be an issue as we move to the new G-codes?
As long as the goals are functional and the documentation contains the G-codes with modifiers, the requirements will be met.
How would we use a progression from walking with a walker to a cane?
Moving from one assistive device to another is not likely to meet CMS requirements for objective, functional measurement instruments without further clarification of the functional deficit. As a suggestion, AM-PAC or FOTO are good ways to provide a numeric value to the functional gains you are describing.
Does coding (G -codes and modifiers) have to be in billing or just in charting documentation?
The G-codes and modifiers must be in both documentation and on the claim.
Can a PTA report on the 10th visit?
Although not specifically stated in this rule, the fact that measurement, assessment and evaluations of goals is required, those are skilled services only provided by a PT.
For speech evaluations, what happens in the case that a swallow study is ordered and no treatment is indicated/delivered? There would be no treatment indicated and therefore no functional goal.
One time visits (i.e.: eval only, splinting, swallow study, etc), need to code the all three G-codes (status, goal and discharge) in the documentation. This is the only scenario when more than two G-codes should be coded for the same discipline on a single date of service.
How does care connections data fit into this process?
Care Connections is an outcomes vendor that would have to map their instrument to the CMS-provided modifier scale.
Do we really need to write goals, if we are using these tools and scales to justify our care?
Yes. CMS maintains G-codes are derivatives of the written and more explicated functional goals. In 2008, CMS updated the manual to include more requirements for functional outcomes reporting. Pub. 100–02, Chapter 15, Section 220.3, Subsection D)
. They assume everyone is already following these requirements and adding 2-4 additional G-codes on the claim are the only additional burden.
As of July 1, what information will need to be submitted for patients who have already been evaluated? Will we need to enter eval G-code at that point?
CMS expects the G-code reporting process and progress reporting frequency to begin and be fine-tuned starting January 1, 2013. There is no penalty until July 1, 2013. What this means is if you are seeing a patient prior to July 1, the 10-visit progress note requirement to update the G-codes will be monitored and enforced. From my perspective, this is probably not something they will get right immediately, but it is probably an easy target in retrospective review.
Does speech choose a G-code for each of the seven areas if the patient has deficits and they are working on multiple areas in therapy or do they choose one of the seven?
Only the primary area of impairment should be coded.
Can you explain how you enter the AM-PAC composite score into the other category for PT, OT and SLP?
The AM-PAC has three domains: Daily Activity, Basic Mobility and Applied Cognitive. Each domain yields a score that converts to a functional modifier. The therapist selects the functional area (G-code) and then applies the modifier that the AM-PAC displays. The Basic Mobility domain maps to either walking or changing position. The Daily Activities maps to either carrying/moving objects or self care. The Applied Cognitive scores can be allocated to swallowing, motor speech, spoken language comprehension, spoken language expression, attention, memory or voice.
Do you use three separate composite scores for each area of the AM-PAC for the different disciplines? For example, applied cognitive score would go under SLP other category?
Yes, sort of. Because there is practice ‘bleed over’ between functional areas and the disciplines that treat them, it is better to think of the AM-PAC domains as mapping to specific functional areas than disciplines. The Basic Mobility domain maps to either walking or changing position. The Daily Activities maps to either carrying/moving objects or self care. The Applied Cognitive scores can be allocated to swallowing, motor speech, spoken language comprehension, spoken language expression, attention, memory or voice.
Where on the CMS 1500 form do you use these codes and do you use them with CPT codes?
Great question. CMS has not posted clear instructions or a sample 1500 form to follow.
Does the KX modifier need to be applied on the new G-codes?
No. CMS clearly stated that the KX modifier should not be applied to G-codes for either professional or institutional claims.
Can the DASH be used for the outcome scale?
Yes. It is on the outcomes calculator at our sister company, MediServe
Yes. Instructions on how to code the claim will be coming from CMS.
Do these codes just go on IE, Re-evals, and DC?
From CMS Transmittal 163: “Specifically, functional reporting, using the G-codes and modifiers, is required on therapy claims for certain 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 — which is the same as the newly-revised progress reporting period — the functional reporting is required on the claim for services on same DOS that the services related to the progress report are furnished;
• The same DOS that an evaluative procedure, including a re-evaluative one, is submitted on the claim (see below for applicable HCPCS/CPT codes);” Here is the list of evaluation codes requiring G-codes on the same date of service: 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 97001, 97002, 97003, 97004, 96125.
They have also stated needing G-codes when switching from primary to subsequent areas of impairment and when a noticeable change in function warrants a reassessment.
Does this Final Rule also include inpatient acute hospitals?
Only Medicare Part B outpatient therapy services furnished at an acute care hospital. If the same rules as therapy caps and manual medical review apply, patients seen in the outpatient observation department for physical therapy services are included in the regulations. This is a good question for clarification by CMS.
During the initial six months (starting in January), will we get any feedback if we are doing it correctly?
It is likely the only feedback you will get is if the G-codes and modifiers were successfully processed by your MAC. CMS has always steered away from dictating how people practice or run their operations.
Is this process just for straight Medicare or HMOs, Advantage Plans, etc.?
The current regulations only apply to Medicare Part B.
Can we use a non-electronic outcome survey instrument such as the Berg?
Yes. CMS only recommends the AM-PAC, FOTO, NOMS and OPTIMAL, but is clear that any valid functional measure can be used.
How do we convert to the 7 point scale if the outcome measure is not on your list? Can it be a straight percentage, i.e. 40/56 = 71%?
First, determine if the scale has an upper and lower bound. If it does, you can take your value and divide by the total range of the scale to get the percentage. Next, you have to decide how to handle the fact that the functional modifier scale is an impairment scale. If the higher the score means the higher the patient performs, you’ll have to use one minus your percent to get the percent IMPAIRMENT, not the percent of functional improvement.
Do G codes/modifiers need to be reported for patients with Medicare as a secondary insurance, or just those with Medicare as primary?
CMS has reversed the position it shared on their Open Door Forum; they do require data collection when Medicare is both primary and secondary.
Could you clarify whether or not care connections is considered a composite tool, or can we use any appropriate G code that we want?
There was a correction made by CMS which encourages therapists to associate a composition score instrument to the primary area of functional impairment. So the question is not whether Care Connections is a composite score or not, it is a clinical judgement if you think CC can validly measure the primary impairment for that patient. If it can, you should pick that functional area’s G-codes and apply the CC score’s modifier to them. Only if it is something like lymphedema, wound care or some ‘other’ type of dysfunction should you use the ‘other Primary impairment’ area.
Where in the initial evaluation should the G-codes and C modifiers be mentioned?
There is no specific instruction on where to put these; however, if the audience you are trying to please is an auditor, I would put it in the assessment and goals section, especially if you are going to over ride the score with professional judgement.
On the 10th visit, if we forget to add the updated codes, will Medicare deny payments or will we be able to add them and resubmit?
You will get denied initially; however, the appeal process has not been clarified yet.
Do we continue to use the MD dx code and PT dx code along with our G-codes?
Yes. CBOR is purely additive from a coding perspective. Change nothing else that you are doing.
What if the 30th day falls on the weekend...do we just close?
The 30 day requirement for progress notes was abolished. It is only required to do a progress note and updated g-codes every 10 days of service.
Are we to only use one G-code, even if there are multiple problems?
You can only code on functional are at a time. That requires two G-codes. The Goal G-code and either the Current Status or Discharge code. Yes, you must transition to a new functional area when the current area is no longer the primary functional area being treated. This transition must be done over two visits / documents. On visit x, you document the goal and discharge codes. On the next visit (visit x+1), you document the Current Status and goal codes for the new functional area of focus.
If a patient presents with Medicare as a secondary payor are we still required to fulfill the CBOR and PQRS measures?
Originally, the answer from CMS was no. Now they ARE requiring it even when Medicare is a secondary payer. Check with your local MAC and be very clear with your question / scenario. Have them reference a document or announcement of some kind (aka: get it in writing.)