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Managing Patient Functional Limitations: CMS Guidelines for Therapy

  
  
  

CMS will require a functional limitation G-code with a severity/complexity modifier for that limitation on all Medicare Part B claim forms beginning on January 1, 2013.  These codes and modifiers must be included on the claim form and in the patient’s documentation.  Testing of these codes and modifiers will begin on January 1, 2013 with final implementation due on July 1, 2013.  Indicators of levels of assistance used previously will no longer be accepted to support patient documentation.  If a provider continues to use such indicators, then patient scoring must be “cross walked” to the new 7 point impairment scale.

Some examples of levels of assistance used previously to measure severity include …

  • Universal Levels of Assistance 5 Point Scale: Independent, CG/Supervision/Set Up, Min. /Mod. A, Max. A, and Dependent.

  • FIM or Functional Independence Measures 7+ Point Scale.

  • Barthel 10 Point Scale.

 

The New CMS 7 Point Impairment Scale

measures the patient’s impairment limitation as indicated below

Functional Limitation Scale

Click Here For A Complete List

Of The New Functional Limitation G-codes

 

Severity/complexity modifiers must be attached to the new G-codes indicating the patient’s primary functional limitation.  G-codes and severity/complexity modifiers must be reported by discipline and are required on the intervals indicated below …

  • Initial Evaluation/POC – Report 2 codes for the current status and projected goal.

  • Every 10th Treatment – Report the projected goal and modifier plus the newly updated functional limitation code and modifier.

  • Upon Discharge – Report the projected goal and the final functional limitation code and modifier.

The projected goal and severity/complexity modifier remain the same throughout treatments addressing the functional limitation identified. 

The example below illustrates how a patient’s functional limitation would be coded and how their severity/complexity would be measured using the new CMS guidelines …

  • On the Initial Evaluation/POC, the patient requires moderate (60%) cognitive cueing assistance for dressing.  Code this as G8987CL (Self-care functional limitation, current status at time of initial therapy treatment; modifier CL = 60% - 79%).

  • A Projected Goal is established at the initial evaluation.  Specifically, a maintenance program for the patient would require minimum (25%) cognitive cueing by caregiver with adapted set up 1 out of 4 times or 1 out of 4 clothing items.  Code this as G8988CJ (Self-care functional limitation, projected goal status at initial therapy treatment; modifier CJ = 20% - 39%).

  • On the 10th Treatment, the patient has improved and now requires moderate (45%) cognitive cueing assistance for dressing.  Code this as G8987CK (Self-care functional limitation, current status at time of reporting interval; modifier CK = 40% - 59%).  Include projected goals with each reporting interval.

  • Upon Discharge, the patient requires minimum cognitive cueing by caregiver with adapted set up 1 out of 3 times or 1 out of 3 clothing items.  Code this as G8989CJ (Self-care functional limitation, discharge status at discharge from therapy/end of reporting on limitation; modifier CJ = 20% - 39%).  The projected goal is also reported upon discharge.

These functional limitation G-codes and severity/complexity modifiers must be recorded in the patient’s medical record and submitted on the UB-04 line item claim form. 

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