Update: New Details on Functional Limitation Reporting Issues

In February, we posted a blog post about a glitch in Medicare’s processing system that was causing claim denials in certain functional limitation reporting cases—specifically, in cases involving complex discharge or treatment scenarios. You can read that blog post in its entirety here. It is imperative to remember that Medicare can only accept data for one functional limitation per patient regardless of how many concurrent cases exist for that patient.

Since writing our original post, we’ve learned additional information regarding FLR problems. Read on to see how the wonky FLR plot has thickened.

Scenario 1: Patient stops coming to therapy but ends up returning within 60 days, and you want to treat the same functional limitation.

If a patient self-discharges and returns within 60 days to receive treatment for the same functional limitation for which he or she previously received treatment, there is no need to complete a discharge note or submit discharge codes. You will simply resume treating, documenting, and reporting FLR data as normal.

As an aside, here is why you should always do a quick discharge note if a patient stops coming to therapy or self-discharges:

Most practice acts require that you complete a discharge note for every patient—regardless of whether the patient self-discharged or had a formal discharge. Within that note, the best practice is to document the patient’s discharge status—or what you believe in your professional opinion to be the patient’s discharge status. That way, you have a basic snapshot of the patient when they left you. If you were unable to complete a formal discharge note, you should complete a quick discharge note. And in that note, you should document the status of the patient’s primary functional limitation even though there’s not a billable visit associated with the note—meaning the FLR data won’t actually be submitted. Then, if for some reason the patient returns within 60 days, you’ll have adequate knowledge of his or her status the last time you saw him or her. While this requires a little extra effort, it’s really about being a better documenter and ensuring that you’re keeping good data in your patient records. Ultimately, you should have follow-up processes in place to get that self-discharged patient back into the clinic for a final visit. With that in mind, you should always assume that a patient will return. To ensure quality treatment, you should want to have the most accurate data possible available.

Scenario 2: Patient is receiving treatment for two different cases from you and another therapist. You have the same specialty and you’re in the same clinic.

Let’s say you have a patient who is currently being seen by a PT in your clinic, and that PT has already established the patient’s primary functional limitation. But then, the patient comes in with a second script for a second, unrelated diagnosis. In this case, you have two options:

1. The PT who is currently treating the patient can complete a re-examination, add the second diagnosis onto the claim, and continue to see the patient for both issues under a single case. Upon reexamination, you feel that the established primary functional limitation should remain, then the re-exam visit claim would then contain five G-codes: Three for a one-time visit charge (i.e., current status, projected goal status, and discharge status for a different limitation) for adding the new diagnosis into the case and two more to reflect the updated current status and goal status of the established limitation. In this scenario, the therapist would need to reassess the established functional limitation to account for any changes that may have occurred as a result of the new diagnosis. In other words, the second diagnosis might impact the current status and goal status for the patient’s established limitation, in which case the therapist would need to adjust these values in accordance with the changes.  If the addition of the 2nd diagnosis requires changing the established primary functional limitation, then 2 codes would be submitted on the re-exam visit claim to discharge the current functional limitation and then on the next daily note, 2 codes would be submitted to establish the new functional limitation for that case.
2. If treatment of the patient’s new diagnosis would be better suited to another PT in the clinic—for example, if it is a knee injury and another therapist in your practice specializes in knees—then the other PT can open a separate case for the diagnosis and begin treating the patient. In this situation, the two therapists must determine which of the two cases represents the patient’s most relevant primary functional limitation. If they conclude that the current ongoing case still represents the patient’s primary functional limitation, then the therapist evaluating the second (new) case will simply complete FLR for the secondary limitation as if it were a one-time visit. That is, the therapist would report with three sets of codes: current status G-code and severity modifier, goal status G-code and severity modifier, and discharge status G-code and severity modifier. This would allow the established functional limitation to remain as primary.

If the two therapists instead conclude that the new functional limitation is more relevant than the established primary limitation, then the therapist who is treating the second diagnosis will discharge the original limitation during the initial examination for the second (new) diagnosis. Then, on the patient’s next visit, the treating therapist—whoever that might be—will record the current status and projected goal status g-codes and severity modifiers for the new primary functional limitation. However, it is imperative that the two therapists collaborate and make sure their respective therapy goals align even though only one therapist is reporting FLR. For example, if the existing case therapist is treating for mobility and the new case therapist finds self-care to be the primary limitation, then both therapists must weave elements of self-care treatment into their plans of care for the patient.

Why do both therapists have to collaborate in this way? Because even though the patient has two separate cases with two separate therapists, Medicare sees only one patient and one specialty. Essentially, the two cases meld into one in Medicare’s eyes. For this reason, the visit count between these two cases is also shared. So, when cases are ongoing concurrently, the visit count is shared between the cases. So, the patient will likely reach the ten-visit progress note mark before either therapist has seen the patient ten times.

To explain this better, let’s run through an example:

Patient Joe comes into see PT Jane for knee pain; she selects the functional limitation Mobility: Walking & Moving Around. This is case #1. A week later, Patient Joe comes into the same clinic to see PT Tom for back pain. This is case #2. PT Jane and PT Tom meet and discuss the two cases. PT Tom believes that the primary functional limitation should now be Carrying, Moving & Handling Objects, and PT Jane agrees. On the initial evaluation for case #2, PT Tom lists the discharge G-codes for case #1 (Mobility: Walking & Moving Around), and he completes the examination. The discharge G-codes will go out on PT Tom’s eval claim. Whichever therapist completes the next daily note will record on that note the current status and goal status G-codes and severity modifiers for the new functional limitation. Let’s say PT Jane completes the next daily note; she’ll record the current status and goal status G-codes for Carrying, Moving & Handling Objects on that note. The ten-visit count begins with the documentation of those Carrying, Moving & Handling Objects G-codes, and that count is now shared between the two therapists. On the tenth visit—again, regardless of which therapist is seeing the patient on that date of service—the therapist must complete a progress note to update Medicare on FLR. If the patient’s tenth visit is scheduled with PT Jane and she neglects to complete her FLR update, all claims following that visit—regardless of case or therapist—won’t be reimbursed. Alternatively, the therapist who is treating the patient’s primary functional limitation—in this example, PT Tom—could ensure he completes a progress note before that tenth visit occurs, thus resetting the visit count.    

Scenario 3: Patient is receiving treatment for two different cases from you and another therapist. The other therapist works in a different specialty (e.g., you’re a PT and he or she is an OT), but you both work in the same clinic.

In this case, you would both report FLR data individually (i.e., completely independent of one another). When concurrent cases exist in two separate disciplines, their respective FLR cases can go on simultaneously. So, a PT and an OT could be seeing the same patient and reporting two different functional limitations (e.g., Carrying, Moving & Handling Objects and Mobility: Walking & Moving Around) at the same time.

Scenario 4: You are treating one patient for two concurrent cases.

Let’s say, for example, you’re seeing a patient for back pain. A few weeks later, the patient brings in a new script for knee pain. If possible, we would recommend combining both diagnoses into a single case. The only reason you would not do this is if you’re actually seeing the patient on different days for each diagnosis—that is, each visit is dedicated solely to the treatment of one diagnosis or the other. If you decide to treat the cases separately, you’ll need to designate one of them as the “reporting case” (i.e., the one for which you will submit functional limitation reporting data). This case should represent the patient’s true primary functional limitation—the one you would prioritize over the other(s).

To explain this more thoroughly, let’s revisit our example from Scenario 2. Only this time, there’s only one therapist: PT Jane.

Patient Joe comes into see PT Jane for back pain; she selects the functional limitation Mobility: Walking & Moving Around. This is case #1. A week later, Patient Joe returns to PT Jane with a script for knee pain. PT Jane wants to treat the patient on separate days for individual diagnoses, so she creates two cases. Knee pain will serve as case #2. That being said, PT Jane believes that the primary functional limitation should now be Carrying, Moving & Handling Objects. So, on the initial evaluation for case #2, PT Jane lists the discharge G-codes for case #1 (Mobility: Walking & Moving Around), and she completes the examination. On the next daily note, regardless of case, she will document the new functional limitation G-codes for Carrying, Moving & Handling Objects. The ten-visit count begins with the documentation of those Carrying, Moving & Handling Objects G-codes, and that count is shared between the two cases. So, PT Jane must make sure she completes a progress note for that limitation on or before the patient’s tenth visit to her clinic.

Alternatively, if PT Jane believes that the primary functional limitation should remain that of case #1 (Mobility: Walking & Moving Around), then she’ll report FLR for case #2 as a one-time visit (i.e., she would report all three G-codes for Carrying, Moving & Handling Objects on the initial evaluation for case #2) and treat without reporting any additional FLR data for case #2. At the same time, she’ll continue to report FLR normally for Mobility: Walking & Moving Around on case #1.

It is important to note that, just as you would do in a situation with two separate therapists as described in scenario 2 above, you should weave elements of your treatment for the patient’s primary functional limitation into your plan of care for the patient’s non-reporting case to ensure that the therapy goals for both cases align and work in tandem. That way, you’ll set the patient up to achieve the best possible outcome.

Scenario 5: I’m getting denials even though I’m doing everything right, and I’m frustrated as all get-out. What should I do?

Not to amplify your frustration, but first let us inform you that Medicare’s “fix” for the 60-day rules is not working—plain and simple. This is most likely why you’re still receiving claim denials even though you’re doing everything correctly. Our recommendation for handling this debacle?

1. Call your local MAC. Also, make sure you check their website as local MAC’s have been posting updates regarding FLR.
2. Submit a complaint form through the APTA if you are an APTA member. The APTA is meeting with CMS bi-monthly to discuss these FLR problems and develop resolutions. But if they don’t know about the problems, they can’t work to resolve them. So, click here to submit your FLR headaches to the APTA, and they’ll present them to Medicare on your behalf. Be sure to also check the APTA’s website frequently for FLR updates.