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Functional Limitation Reporting Processes: The Pursuit of Perfection

Feb 21 | , , , ,

My kids love playing the classic, heart attack-inducing game Perfection.  For those of you who have never played Perfection, the object of the game is very simple: fit all these little, shaped pieces in a grid within a minute and then stop the timer before the whole grid blows up in your face.  Fun, right?  On the surface, it doesn’t seem like it should be all that hard.  You know exactly how much time you have, and everything is laid out right there in front of you.  It reminds me a bit of CMS’s functional limitation reporting initiative.  We knew for a long time that we needed to be ready by July 1st, and Medicare gave us all the information well in advance.  (Well, most of it.)  When you really look at it, though, there are a lot of pieces to consider, and the repercussions of failing to get everything done on time are not pleasant.  With Perfection, it’s the threat of a cardiac event.  With functional limitation reporting, it’s the threat of unpaid claims.

By now, most of you will already have a pretty good idea as to whether or not you are successfully submitting your claims with the functional G-codes within the prescribed parameters.  However, if you are new to the game, if you are unsure why your claims are being returned unpaid, or if you just want to make sure everything will stand up in an audit, then you may want to consider a few key points to ensure all of your pieces are in the right place.

Are you reporting the correct number of G-codes and with the correct modifiers?

  • If your claims are getting returned unpaid, it could be because of the lack of appropriate modifiers.  The G-codes for functional limitation reporting must include the corresponding severity modifier as well as the therapy modifier indicating the discipline of the plan of care, e.g. GP for PT or GO for OT.  (This is a little different from PQRS in which the QDCs used for reporting the various measures should NOT have the GP or GO modifiers appended.)
  • No KX or -59 modifiers should be appended to the G-codes used for functional limitation reporting.
  • The “units” field is required to be completed for the functional G-codes.  Use a “1” to complete this field for each functional G-code reported.
  • Make sure you are reporting the correct number of G-codes.  You will typically report two G-codes at each required reporting (the current status and projected goal OR the discharge status and the projected goal).  Exceptions to this include situations in which the visit is a one-time visit or the clinician is reporting an evaluative procedure for a separate plan of care in which case all three G-codes (current status, projected goal, and discharge status) will be reported AND in situations in which a beneficiary is receiving services on the same treatment date from more than one therapy discipline.
  • If a therapist decides to end reporting for a primary functional limitation and begin reporting a secondary limitation, the reporting for these should not be occurring on the same day.  To end reporting for the primary limitation, the therapist should report the discharge status and projected goal for the primary limitation.  The current status and projected goal for the subsequent limitation should be reported at the NEXT treatment visit.

Does the documentation include the necessary G-codes, severity modifiers, and how the therapist determined the severity modifier?

  • CMS clearly states that the documentation of the G-codes and severity modifiers must be included in the patient’s medical record for each required reporting, including how the severity modifier selection was made.
  •  In documenting how the severity modifier was determined, the therapist should include any relevant information used in selecting the functional limitation percentage.  This may include scores from any assessment tools, such as patient self-report or performance-based instruments, as well the therapist’s clinical judgment in applying the relevance of those scores to additional patient data obtained through the assessment process, such as co-morbidities, age, cognition, and objective findings such as pain, ROM and strength deficits, etc.

Are you reporting at the proper intervals?

  • Functional limitation reporting is required at the outset of a therapy episode, when an evaluative procedure is furnished and billed (including re-evaluations), when reporting for a particular functional limitation is ending, when reporting for a subsequent limitation is begun, at the time of discharge, and at least once every 10 treatment days (which corresponds with the progress reporting period).
  • It is imperative that therapists accurately track patient visits to know when progress reports are due and when reporting is required.  If the therapist did not submit the functional limitation codes for inclusion on the claim and those G-codes are not documented in the medical record for a date of service for which reporting was required, that visit will be unpaid.
  • Another area that has seemed to create a bit of confusion is the timing of the 10th visit.  Per the Medicare Benefit Policy Manual, “The minimum progress report period shall be at least once every 10 treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment. Regardless of the date on which the report is actually written (and dated), the end of the progress report period is either a date chosen by the clinician or the 10th treatment day, whichever is shorter.”  Per the MLN Matters Number 1307, “A reporting period covers the same period as progress reporting.  A clinician (therapist, physician, or NPP) is required to report once every 10 treatment days.  A reporting period is defined as the period from the first reporting of functional codes until reporting at the 10th treatment day. For subsequent reporting periods, the first visit is the treatment date following the 10th treatment date.”  So, functional reporting is required at the initial visit, on the 10th treatment day, and then at least every 10 visits thereafter.  Reporting may, of course, occur earlier than every 10thvisit, in which case the next reporting interval would start on the next treatment day.  For example, if a therapist decided to do a progress report with functional limitation reporting at the 7th visit instead of the 10th visit, the 8th visit would restart the visit count for the next reporting interval, making the next progress report (and functional limitation reporting) due on the 17th visit.

These are just a few key elements to remember as you assess your processes for functional limitation reporting.  There are obviously many others, but the above points address some common areas that could serve as pitfalls.  You may also click here to access a sample functional limitation reporting self-auditing tool.  For additional information, please feel free to contact Stephen Huntsman at  Here’s hoping you achieve “perfection” in the processing of your functional limitation reporting codes!