Functional Limitation Reporting and You: What You Need to Know

Wow, can July 1 really be right around the corner? Seems like yesterday we were only finding out about the requirement to document and report functional limitation G-codes and severity/complexity modifiers, and I think it really was only yesterday that CMS figured out how they would work.

Let me start by making sure you understand that functional limitation reporting (FLR) and PQRS are separate and distinct programs and that each program has its own set of codes to report. They are not the same. What I would like to do today is answer some common questions that I have received about FLR G-codes and modifiers. Let’s start with:

What’s important to know?

Participating in FLR is mandatory. Reporting the appropriate G-codes and modifiers is a condition of payment. Needless to say, anytime CMS modifies our condition of payment, we have to take it seriously. Fortunately, it is not that difficult to comply with these changes.

What’s the same?

You are still going to perform the same thorough initial evaluation you’ve been performing. In your evaluation you are going to continue to identify and objectively measure all of the physical impairments that will require your skilled intervention to treat. Your evaluation will also identify and objectively measure all the functional limitations that the patient has that are a result of their recent impairments.

So what’s new?

After we have identified all the patient’s functional limitations, we are required to pick one functional limitation and the severity of that limitation along with the goal for that functional limitation to report to Medicare. We have two options:

• Pick a functional limitation for which you feel you can make rapid progress.
• Pick the functional limitation that is most important to your patient.

Obviously, you should always choose what is best for your patient. However, if there is a time where what’s best for your patient intersects with the opportunity for you to document rapid progress, then I encourage you to go this route. Part of the reason Medicare is collecting this data is to determine a future means of payment for the services we provide. When possible and suitable, it’s in our interest to show how rapidly a patient can recover function thanks to our services.

To identify the patient’s functional limitation, you will use a functional outcome tool and combine the results of that with your professional clinical judgment. Don’t be afraid to use your judgment just because you (or other therapists) have in the past experienced discrepancies among what you objectively measured, the subjective reports of improvement from the patient, and what the functional outcome tool scored. Instead, try documenting something like: “Based on the objective improvement in pain, AROM, and strength, and based on the patient’s subjective report of being able to walk upstairs with a reciprocal gait and one handrail, it is my clinical professional judgment that the patient’s mobility (G8978) severity rating is now 30% (CJ). This represents a significant 20% improvement over the past ten visits.”

To meet this new condition of payment, you must report the FLR G-codes and modifiers at the initial evaluation, at the ten-visit progress report (at minimum), whenever you perform and bill a re-evaluation (97002), and at the end of reporting that functional limitation or at the discharge of the patient. You must report the FLR G-codes and modifiers within your documentation on that date of service as well as in your plan of care and on your claim to Medicare.  You must submit the FLR G-codes and modifiers with a billable CPT code, for example, 97001, 97002, or 97110.

Do I have to wait until the tenth visit to report on progress? 

Absolutely not! If you have a patient who is making exceptional progress and you want to capture that progress and report it, you are free to do so. The new requirement for completing a progress report is on or before the tenth visit throughout the episode of care. If you were to report progress on the eighth visit, for example, and you were continuing treatment, you would start counting again from there. So on or before the 18^th visit would be the next progress report. 

What do I do if the patient meets the first functional limitation goal? 

Excellent! Report the discharge status and severity modifier and the goal status and severity with that progress report. If the patient has met all the goals, discharge. If there is another area of functional limitation remaining and there continues to be physical impairments that require your skilled interventions to resolve (and you have objective measures of everything and the patient has the rehab potential to achieve the goals), then report the new functional limitation and its goal on the very next visit. 

Can I change or progress my goal? 

Absolutely. We can continue to make all the professional judgments we normally make. So, if you get to the first progress report and the patient has made excellent progress and you feel, in your clinical professional judgment, that you may have underestimated how much progress the patient will make, you may change the goal. For example, the initial goal might have been for a “CJ,” but after treating the patient for ten visits, you feel the patient will be a “CI.” You can make that change as long as it falls within your objectively identified prior level of function. 

What if I forget to list the FLR G-Codes and modifiers on my claim? 

You will get a remittance report back from your MAC (Medicare Administrative Contractor) that your claim was “rejected” for insufficient information to process the claim. It is important to realize that this is not a “denial.” If you get a rejection, you do not have to go through the appeal process. Simply amend your note and resubmit the claim with the correct G-codes and modifiers. 

What if I don’t have the information (G-codes and modifiers) to place on the claim? 

WebPT Members won’t have to worry about this, as the WebPT system will not allow you to finalize a note until you’ve completed the required reporting. For those of you not yet using WebPT, I’m not sure exactly how this is going to work, to be honest. I know Medicare will not pay the claim for which FLR was required, but as for approval or rejection of subsequent claims or whether you’ll have to eat the cost of the denied claims, I’m unsure.  I suppose we will all find out together after July 1.

In closing, do not make this harder than it is. Continue to evaluate thoroughly and document objective measures and your professional clinical judgment. Report on one functional limitation and severity at a time along with the goal and comply with the new condition of payment. If you have questions, please post them as comments below or email functionallimitation@webpt.com.