Just When You Thought You Had It All Figured Out

You did everything you knew to do. You educated yourself. You trained your staff. You knew this stuff backwards and forwards. Yet, here you are in the first quarter of 2014 scratching your head trying to figure out why your Medicare claims are being returned unpaid because of functional limitation reporting issues. Well, you’re not alone. Providers everywhere are having claims returned unpaid for a myriad of reasons. Unfortunately, the reasons are multiple and the answers are few at this point.

WHAT DID I DO WRONG?

Most likely, you did everything exactly right. Granted, that probably doesn’t make you feel any better since that won’t help your collections. Most of the issues revolve around things that are completely outside of your control. A quick review of some of the problems that have been identified:

Visit Counts: In some instances, the carriers have simply not counted the visits correctly and have been returning unpaid any visits which they perceive are missing functional G-codes.

October 1 Restart: We all made sure we were compliant with Functional Limitation Reporting by July 1st per the directives passed down by CMS. However, the edits weren’t turned on until October 1st. (That’s why everything seemed to be going so smoothly at first.) The turning on of the edit on 10/1/13 apparently reset the visit count which meant carriers were expecting to see the reporting of G-codes on the first visit on or after that date (as they had mentioned would be the case for 7/1/13 in their instructions to providers). Providers were oblivious to the fact that the edits had not been turned on until 10/1/13 and that they would need to restart their visit counts after that date.

Early Reporting: As allowed in the instructions to providers, therapists could complete progress reports and submit functional G-codes earlier than the 10th visit with the next reporting period beginning on the next visit. However, providers have seen instances in which reporting was still required on the 10th/20th/etc. visits despite the fact that the reporting had occurred at an earlier visit.

Multiple Conditions/POCs: CMS indicated in its MLN Matters Number SE 1307 and in its FAQ document that a when a clinician reported an evaluative procedure for a different functional limitation that what they were currently reporting, the evaluative procedure furnished for the second/different functional limitation should be reported as a one-time visit (i.e., report all three (3) G-codes in the code set for the functional limitation that most closely matches that for which the evaluative procedure was furnished). The ongoing reporting of a primary functional limitation would then not be affected when all three (3) G-codes in a code set are reported for the evaluative procedure for a second functional limitation. Apparently, this has created some issues as the system has not wanted to recognize the reporting of a secondary limitation before a primary limitation has been discharged.

Claims Splitting: In instances where many codes are being submitted (e.g. CPT codes, QDCs for PQRS and functional G-codes for Functional Limitation Reporting), the MACs are splitting the claims. As a result, the evaluation codes are being processed separately from the functional G-codes. The evaluation is then not being reimbursed because the functional G-codes aren’t showing up with the evaluation code.

SO WHAT CAN WE DO?

While several of these issues are obviously beyond your control, there are a few things you can do to make sure your claims are processed cleanly.

• Place the functional G-codes on the claim directly after the evaluation code (if charged) or procedural codes.
• Make sure to attach the therapy modifiers (GP for PT, GO for OT) to the functional G-codes.
• Use a penny charge as opposed to zero charge for the functional G-codes.
• Make sure clinicians are using the correct combination of G-codes (e.g. current status and projected goal or projected goal with discharge status, NOT current status with discharge status).
• If changing functional limitation categories, make sure to discharge the primary limitation and then begin reporting the secondary limitation at the NEXT visit.

Lastly, if any of your clinicians are members of the APTA, they can access an online complaint form on the association’s website where they can share issues regarding the processing of claims with the functional G-codes. The APTA will share that information with CMS as they work toward resolving these issues.

Hang in there!