UHC to Implement FLR for Medicare Advantage Plans Starting August 1st

We have known for a couple of months now that United Healthcare plans to implement functional limitation reporting for its Medicare Advantage Plans effective August 1^st, 2014.  Per United Healthcare’s May 2014 Network Bulletin, contracted physical, occupational, and speech therapist claims with dates of service on or after 8/1/14 will require functional G-codes and accompanying severity modifiers to be appended when one or more of the following CPT codes are billed:  92521-92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004.  The bulletin states that claims submitted with applicable CPT codes that do not contain the appropriate functional G-code and severity/complexity modifiers will be rejected.

What we do NOT know at this point is whether or not UHC intends for reporting to also be required at least every 10 visits and at discharge as per Medicare’s requirements.  The May Network Bulletin states “Once implemented, the policies may be viewed at UnitedHealthcareOnline.com > Tools & Resources > Policies and Protocols > Reimbursement Policies.” It would seem prudent to release those policies BEFORE the implementation date so providers can know if they need to report both a current status and a projected goal when an evaluative procedure is billed, if and when follow-up reporting will be required, if discharge reporting will be required, how to handle scenarios involving multiple plans of care, etc.  One has to question the rationale for requiring functional limitation reporting only when an evaluation or re-evaluation is billed if periodic follow-up and discharge reporting are not also required.

The APTA has recently submitted a letter to UHC urging them to stop its planned implementation of functional reporting for MA plans citing the difficulties experienced by therapists during Medicare’s implementation of the requirements and pointing out the limitations in the data.  Hopefully, we will learn more in the next week prior to the scheduled implementation date.  If not, we will (as we’ve done before) learn as we go.  Stay tuned for more updates.