G Code Reporting

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The Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA; Section 3005(g); see http://www.gpo.gov/fdsys/pkg/CRPT-112hrpt399/pdf/CRPT-112hrpt399.pdf) states that “The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes.

This claims-based data collection system is being implemented to include both 1) the reporting of data by therapy providers and practitioners furnishing therapy services, and 2) the collection of data by the contractors. This reporting and collection system requires claims for therapy services to include nonpayable G-codes and related modifiers. These non-payable G-codes and severity/complexity modifiers provide information about the beneficiary’s functional status at:

• The outset of the therapy episode of care,
• Specified points during treatment, and
• The time of discharge.

These G-codes and related modifiers are required on specified claims for outpatient therapy services – not just those over the therapy caps. 

Application of New Coding Requirements

This functional data reporting and collection system is effective for therapy services with dates of service on and after January 1, 2013. However, a testing period will be in effect from January 1, 2013, through June 30, 2013, to allow providers to use the new coding requirements in order to assure that their systems work. During this time period claims without G-codes and modifiers will be processed.

The reporting and collection requirements of beneficiary functional data apply to all claims for services furnished under the Medicare Part B outpatient therapy benefit and the PT, OT, and SLP services furnished under the Comprehensive Outpatient Rehabilitation Facility (CORF) benefit. They also apply to the therapy services furnished incident to the service of a physician and certain Non-Physician Practitioners (NPPs), including, as applicable, Nurse Practitioners (NPs), Certified Nurse Specialists (CNSs), and Physician Assistants (PAs).

These reporting requirements apply to the therapy services furnished by the following providers: hospitals, Critical Access Hospitals (CAHs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), rehabilitation agencies, and Home Health Agencies (HHAs) (when the beneficiary is not under a home health plan of care). It also applies to the following practitioners: Therapists in Private Practice (TPPs), physicians, and NPPs as noted above.

Resources:
http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/FunctionalReportingNPC.pdf
http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/TherapyFunctionalReportingG-codes.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8126.pdf

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