Functional Reporting

Spotlight

Discontinuation of Functional Reporting for PT, OT, and SLP Services

The Functional Reporting requirements of reporting the functional limitation nonpayable HCPCS G-codes and severity modifiers on claims for therapy services and the associated documentation requirements in medical records have been discontinued, effective for dates of service on and after January 1, 2019. The below instructions apply only to dates of service when the functional reporting requirements were effective, January 1, 2013 through December 31, 2018.

For more information regarding the ending of Functional Reporting please see the pages for Therapy Services (section II.L.) of CMS-1693-F on the CMS web page at the following link for Physician Fee Schedule (PFS) Federal Regulation Notices:   /Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.

Functional Reporting

Functional Reporting gathers data on beneficiaries’ functional limitations during the therapy episode of care as reported by therapy providers and practitioners furnishing physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services. The Functional Reporting system will better our understanding of beneficiary conditions, outcomes, and expenditures. This system was established through the Calendar Year (CY) 2013 Physician Fee Schedule final rule (77 Federal Register 68958). Implementation of the claims-based data collection strategy for outpatient therapy services was required by The Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA).

Application of Coding Requirements

Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report nonpayable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.

Functional Reporting is required on therapy claims for certain dates of service (DOS) as described below:

• At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;
• At least once every 10 treatment days on the claim for services on the same DOS that the services related to the progress report are furnished;
• At the DOS that an evaluative or re-evaluative procedure code is submitted on the claim; and
• At the time of discharge from the therapy episode of care, unless discharge data is unavailable, e.g., this may occur when the beneficiary discontinues therapy unexpectedly.

For a comprehensive understanding of the Functional Reporting requirements during an episode of care, refer to the links within the “Resources for Functional Reporting” section below.

Functional Reporting Codes — G-codes

G-codes are used to report a beneficiary’s functional limitation being treated and note whether the report is on the beneficiary’s current status, projected goal status, or discharge status. There are 42 functional G-codes that are comprised of 14 functional code sets with three types of codes in each set. Six of the G-code sets are generally for PT and OT functional limitations and eight of G-code sets are for SLP functional limitations.

Providers and practitioners report the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment.

Functional Reporting Codes — Severity/Complexity Modifiers

For each non-payable G-code reported, a modifier must be used to report the severity level for that functional limitation. The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the providers or practitioners furnishing the therapy services. Therefore, the beneficiary’s current status, projected goal status, and discharge status are reported via the appropriate severity modifiers.

For a complete list of the Functional Reporting G-codes and Severity/Complexity Modifiers, refer to the Functional Reporting Quick Reference Chart (PDF). For a complete understanding of how to properly select a functional limitation and determine a severity level, refer to the links within the “Resources for Functional Reporting” section below.

Documentation Requirements

Providers are required to document in the patient’s medical record the functional G-codes and severity modifiers that were used to report the patient’s current, projected goal, and discharge status. For the severity modifiers, providers should include a description of how the modifiers were determined. These requirements are applicable for each date of service for which the reporting is done.

Resources for Functional Reporting

Federal Regulation: CY 2013 Physician Fee Schedule Final Rule

National Provider Call: See the Preparing for Therapy Functional Reporting Implementation in CY 2013 National Provider Call Details page for the slide presentation, audio recording, and written transcript from the call; as well as a list of Therapy Functional Reporting G-code Short Descriptors, and MLN Matters Article MM8005 – “Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services”.

MLN Special Edition Article 1307: Outpatient Therapy Functional Reporting Requirements (PDF)

CR 8005: Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services — Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 (PDF)

Frequently Asked Questions (FAQs): Functional Reporting FAQ Document (PDF)

Pub. 100-02: Medicare Benefit Policy Manual, chapter 15, section 220 (PDF) for more details on the Functional Reporting requirements at specified points during the therapy episode

Pub. 100-04: Medicare Claims Processing Manual, chapter 5, section 10.6 (PDF) for details about the Functional Reporting requirements on claims for therapy services

If you have any questions, please contact your Medicare contractor at their toll-free number, which can be found by visiting the Provider Compliance Interactive Map.