CMS Alerts Providers About Additional FLR Issues

As a follow-up to my previous blog entry on functional limitation reporting issues, I wanted to share a few additional points that have come to light in the last few weeks.  We previously discussed the fact that CMS has acknowledged multiple issues with the processing of claims with functional G-codes including the splitting of claims, MACs incorrectly counting visits toward the reporting timeframes, MACs still requiring reporting at the 10th visit when reporting was submitted earlier than the 10th visit, and a restarting of reporting for active episodes on 10/1/13 when the MACs actually turned on the edit (instead of the July 1st deadline that was communicated to providers).

More recently, a few of the MACs have distributed information pertaining to a couple of specific problems.  According to recent updates from Palmetto and Noridian, CMS is aware of two specific issues:

1.  Certain initial therapy services are rejecting incorrectly indicating the provider did not submit the patient’s functional current status and the paired functional goal status G-code/severity modifier.

2.  Claims are rejecting when a claim is submitted with a different functional G-code set than is currently indicated in the patient’s HIMR history, e.g. when the patient has not been discharged and both sets of functional reporting have the same billing provider NPI and same discipline (GN, GO, or GP modifier). The system is not recognizing an episode of care when 60 days have lapsed since the last billed date of service for the initial G-code set. Therefore, the initial episode of care is not closing which prevents the second episode of care from being recognized.

The claims are being returned with CO-4 (“The procedure code is inconsistent with the modifier used or a required modifier is missing”) and N572 (“This procedure is not payable unless non-payable reporting codes and appropriate are submitted”).  A system fix was loaded on March 24, 2014 to address some of the therapy claim issues.  CMS has advised that providers may begin to refile their incorrectly rejected claims and that they will continue to monitor the system fix and research additional issues with therapy claims.

Lastly, as part of a recent discussion between CMS and the APTA, CMS explained that its current system can accommodate no more than 13 line items on a 1500 claim form. CMS advised that providers may experience more efficient processing and find their claims less likely to be split if they submit claims with no more than 12 line items.  It has also been suggested that when reporting on a DOS which includes an evaluative procedure (e.g. 97001, 97002, 97003, or 97004) that the functional G-codes and their associated modifiers be listed immediately following the evaluation or re-evaluation CPT code.  If additional lines are required for PQRS and other treatment codes, it has been suggested that the PQRS codes be placed immediately following the functional G-codes and then if a separate claim form is needed to accommodate any remaining codes that it be used for the billing of the treatment CPT codes.

It would be wise to keep a close eye on your Medicare aging reports and review your EOBs to identify any problem areas.  The APTA has set up an online complaint form for its members to report any problems they may be having in getting their claims paid.  The APTA plans to share this feedback with CMS as they continue to work out the kinks.  (Access to the online form requires an active APTA membership.)  Keep in mind, though, that not all issues are on the payor side.  Your EOB reviews will also help you identify any mistakes your providers may be making such as not reporting at the proper intervals, using the wrong combination of G-codes (a common error is therapists reporting the current status and discharge status at the discharge visit rather than the projected goal and the discharge status), or failing to apply the correct modifiers.  A thorough EOB review will help you identify areas that need to be reinforced with your staff.

Stay tuned for more updates.