PTs Rise to 2013 G code Challenge

Follow physical therapy service requirements for new G code and modifier reporting.

By Lynn S. Berry, PT, CPC

A new, claims-based collections system implemented through the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule calls for adding non-payable G codes with additional severity modifiers on each therapy claim—along with the normal charges and therapy modifiers and applicable Physician Quality Reporting System (PQRS) codes and modifiers.

Rule of Thumb for G Code Use

In the final rule, the Centers for Medicare & Medicaid Services (CMS) instructs us to use G codes and severity modifiers during:

• The initial treatment
• Defined progress periods
• Any subsequent evaluation or re-evaluation
• The end of care (or discharge)
• When reporting of the primary functional limitation has ended with further therapy required
• When reporting begins on a different or subsequent functional limitation

G codes signify the patient’s primary impairment as determined by the therapist. The therapist determines the severity by using a standard set of functional outcome measures denoted by a severity modifier added to the G codes. A G code with a severity modifier is also required for the projected outcome of the patient (the patient’s goal).

The measures for both the goal and the initial level of impairment should be noted in the patient’s plan of care; the goal and current level of impairment should be noted in progress reports no later than every 10 treatment days (a new definition of progress report time frames); and the goal and final level of impairment should be noted in the discharge note or when the goal is reached. For most claims, two G codes are required, with two exceptions:

• When therapy services are under multiple plans of care (physical therapy (PT), occupational therapy (OT), and/or speech-language pathology (SLP)) from the same therapy provider; or
• When it is a one-time visit and all three G codes (current status, goal status, and discharge status) must be reported.

Know Therapy G Codes and Severity Modifier Requirements

To provide an audit trail, the G codes and severity modifiers, their rationale for use, and the pertinent tests provided need to be documented in the medical record. After the primary impairment goal is reached, secondary impairments may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer. The G codes and severity modifiers for PT, OT, and SLP are noted in the final rule (and shown in Table A).

Select only one impairment as primary. If a specific category does not apply, or if using a composite functional measurement tool, select the “other” category. Each impairment category has three applicable codes.

Note: The SLP G codes are aligned with their functional reporting system, the National Outcomes Measurement System (NOMS). For SLP, the “other” category is used for any of the eight remaining NOMS categories not specified in the rule.

Table A: G codes  for 2013

Table B: Severity modifiers for reporting therapy G codes

The severity/complexity modifiers for reporting each functional G code on the claim are shown in Table B.

Here is an example of how to use G codes on a claim:

A 66-year-old patient presents at the clinic and receives a full initial evaluation, including specific impairment and functional measures testing and administration of three PQRS outcome measures: falls, body mass index, and pain level. A plan of care is developed (with specific goals based on the patient’s impairments, co-complexities, and severity) to submit to the physician for certification. Treatment is initiated as specified in the plan. Documentation is completed, and includes all of the tests and measures used and the rationale for the treatment and severity modifier chosen. G codes and modifiers are added to the documentation. The claim is filed for the patient for the date of service with the following entries:

97001 GP X1      $XX.00

97112 GP X1        XX.00

97116 GP X1        XX.00

G8978 GPCL         0.00

G8979 GPCI          0.00

1101F                   0.00

G8731                   0.00

G8417                   0.00

Note: Modifier GP Services delivered under an outpatient physical therapy plan of care (or “other therapy” modifier) must be added to the data codes because they are always therapy codes. The order does not matter when assigning the therapy or severity modifier. Therapy modifiers are not required to be added to PQRS codes. Neither modifier KX Requirements specified in the medical policy have been met nor modifier 59 Distinct procedural service can be used with these G codes. These codes are not only added for 2013, but CMS notes they will continue to require data code submission until a new payment system is developed.

March 1st, 2013

1 Comment

HITECH-related HIPAA Changes Final

Dramatic modifications to the Health Insurance Portability and Accountability Act’s (HIPAA) Privacy, Security, Enforcement, and Breach Notification Rules that will impact your practice are finalized and begin to take effect next month.

The omnibus final rule, developed to help implement HITECH regulations in the American Recovery and Reinvestment Act and shore up electronic privacy rules in the 17-year-old act, includes changes to how providers and payers must protect personal health information (PHI) and the focus of enforcement from voluntary to punitive. The rule also makes business associates (BA) more accountable for breaches of PHI, with the risk of financial penalties.

The Centers for Medicare & Medicaid Services (CMS) maintains the changes provide the public with increased protection as penalties are increased for noncompliance based on the level of negligence with a maximum penalty of $1.5 million per violation. The changes also strengthen the HITECH breach notification requirements by clarifying when breaches of unsecured health information must be reported to HHS. These changes broaden who is responsible and extends consequences to more parties, including small practice, payers, and BAs like billing services or clearing houses.

CMS says the new rule expands individual rights. For example, patients can request a copy of their electronic medical records in electronic form. When individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan. The omnibus rule sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of an individuals’ health information without their permission.

The rule also streamlines individuals’ ability to authorize the use of their health information for research purposes. The rule makes it easier for parents and others to give permission to share proof of a child’s immunization with a school and gives covered entities and BAs up to one year after the 180-day compliance date to modify contracts to comply with the rule, the health agency says.

• The new rule increases liability for noncompliance for practices. Tiered penalties range from $100 to $50,000 per violation, depending on culpability. Under the new rule, HHS can impose monetary penalties without exhausting informal options.
• The new rule imposes direct liability for BAs and subcontractors, a change that puts billing services and their clients more at risk because a practice is now liable for what its billing service does.
• The rule introduces an objective test of whether PHI has been compromised and requires notification. The four elements are:
  • Nature and extent of PHI in the incident
  • Recipient of the PHI
  • Acquisition or viewing status of PHI
  • Mitigation of the risk after disclosure
  • The new rule requires patient authorization for all communication of PHI for marketing purposes, closing a loophole that allowed health care organizations, drug companies, and others to use PHI for direct marketing to patients without permission.
  • The new rule better defines what a BA is, clarifying how much interaction with PHI an entity can have before it becomes a BA, and establishing additional accountability for those entities.
  • The rule loosens what can be used for fund-raising communications, allowing demographic information, dates of service, department, physician, outcome, and payer status for fund-raising and related BAs. Patient authorization is required.
  • The rule makes it easier for your patients to authorize PHI to be used for more than one research effort, allowing a patient to designate PHI can be used for multiple and future research efforts at once.

Overall, the new rule clarifies the definition of a covered entity or BA, the responsibilities that each carry, and punishments associated with a lack of compliance. It doesn’t change the basics; an entity or BA must still have a plan, a designated compliance officer, education, analysis of gaps, and privacy notices for patients and their family members. Under the rule’s changes to definition of compliance, culpability, and correction, however, practices need to reassess efforts this year to avoid unexpected fines or punishment.

February 22nd, 2013

1 Comment

Know When HITECH Trumps Payer Contracts

With so many Health Insurance Portability and Accountability Act (HIPAA) changes coming down the pike, it’s a great time to look at how privacy and security laws may impact your practice and compliance plan.

In a recent U.S. Department of Health & Human Services (HHS) press release, HIPAA expands the individual rights of patients to their health information. According to the press release, “The final omnibus rule greatly enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law.”

This means patients can ask for copies of their electronic health records (EHRs). And when it comes to billing, it also means a patient who wants to pay cash can instruct the provider to not share treatment information with his or her health plan.

Keep Billers Compliant

According to Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CHCC, here is why it is important to not bill insurance when a patient pays out-of-pocket:

“Although HITECH does not address billing directly, when a patient pays for a service out-of-pocket and instructs (through an appropriate ‘Restrictions on Uses and Disclosures Form’) that you may not disclose PHI associated with that service for payment or health care operations, you are prevented from submitting a claim since by doing so you would be disclosing PHI. If you chose to bill the service anyway, it would be an unauthorized disclosure constituting a breach. This may subject the provider to a penalty, which could be quite substantial if OCR determines the conduct was reckless (usually due to incomplete or non-compliant HIPAA privacy and security policies). Therefore, when the patient makes such a request, HITECH trumps any perceived contractual duty to file a claim because it can’t be done without violating a federal law. A contractual provision that requires you to violate a law is generally unenforceable.

Usually, the patient is paying cash because the service is non-covered. Most provider contracts as well as the Medicare statute do not require submission of claims for non-covered services on behalf of the beneficiary in any event.”

Under the pre-HITECH regulations, you could ignore the patient’s request not to file the claim. Under HITECH, you cannot.

Practical Advice

If a patient pays in full out-of-pocket and does not want to bill insurance, according to Miscoe, here are the best steps to take to stay compliant with HITECH:

• Have the patient sign a request that information relative to self-paid services not be disclosed (usually called a Restrictions on Uses and Disclosures Form). Note that self-paid services do not include circumstance where the patient ultimately pays the entire value of the service because of a deductible. The patient’s signed restriction on such disclosures absolutely precludes the provider from submitting a claim for those services. As noted above, the provider is protected from any allegation regarding provider contract breach for not billing by the patient or the carrier, even assuming such an obligation existed.
• Flag these records somehow so they are not disclosed to the health plan should the health plan make a request. The easiest way is to keep them in a separate file. If that’s not an option, clearly mark the record as “Not for Disclosure for Payment or Health Care Operations.”
• If you are sending the records to another provider (which is permissible), make sure the provider knows the records cannot be sent to the health plan due to the patient’s request. A big red stamp or other notation saying the records may not be disclosed in response to a carrier’s payment or health care operations request should suffice.

February 15th, 2013

8 Comments

2013 OPPS: Up 1.8 Percent

By Denise Williams, RN, CPC-H

CMS estimates an “overall” rate increase, but changes cost methodology.

In the 2013 Outpatient Prospective Payment System (OPPS) final rule, the Centers for Medicare & Medicaid Services (CMS) bases payments on claims data submitted by hospital providers during 2011. CMS is changing the calculation based on median cost to geometric mean cost, citing this methodology will result in payment rates more accurately reflecting the cost of providing services. CMS believes this means improved data under the OPPS, and improved payment policy. CMS notes there will be some fluctuation in the relative weights used for calculating payment, but as the costs are realigned, the fluctuations should stabilize over time.

Understand the Master Plan

CMS estimates payments under the OPPS will increase overall by 1.8 percent compared to 2012 (see Chart A for a six-year conversion factor history); however, there continue to be other factors involved that will affect payments. Payments to community mental health centers (CMHC) will decrease by 3.9 percent due to the relative weight being based on geometric mean cost rather than median cost.

The payment adjustment for dedicated cancer centers will continue for calendar year 2013. Because these centers provide cutting edge therapies and procedures, their cost is higher on average than other facilities. CMS recognizes this, and the adjustment is to offset their higher-than-usual cost. Since the OPPS contains a budget neutral requirement, CMS must shift monies from other facilities to the cancer centers to make the adjustment.

Chart A

CMS reviewed comments regarding intraoperative radiation therapy (IORT) services represented by CPT® codes 77424 Intraoperative radiation treatment delivery, X-ray, single treatment session and 77425 Intraoperative radiation treatment delivery, electrons, single treatment session. These services are not the typical intraoperative services considered integral to or dependent on the surgical procedure because these are actual radiation therapy services provided while a patient is in the operative suite. These services will no longer be packaged for 2013 and are assigned to Ambulatory Payment Classification (APC) 0412.

It appears CMS has abandoned the establishment of national guidelines for reporting visits under the OPPS. The final rule notes, “it would be disruptive and administratively burdensome” to require hospitals that have successfully implemented internal guidelines to implement new national guidelines. CMS acknowledges new guidelines would have to be implemented by thousands of hospitals and inevitably create new problems that would need to be addressed.

You can download the CMS display copy of the rule and all addenda. Select CMS-1589-FC to download the final rule: “Hospital Outpatient Prospective Payment – Final Rule with Comment Period and CY 2013 Payment Rates.”

Composite APCs Remain the Same

No new composite APCs were created for 2013; however, new CPT® codes have been established to combine electrophysiological (EP) evaluations with ablations and have been assigned to the composite APC. Previously, composite payment was triggered when an EP evaluation and ablation were reported on the same date of service, so the cost for both studies was included in the payment calculation. Assigning new CPT® codes for the combination services to the composite APC should maintain consistent payment rates.

Outlier Fixed-dollar Thresholds Updated

CMS annually updates the formula for calculating outlier payments. Consistent with prior years, for 2013 an outlier payment will be triggered when costs for providing a service or procedure exceed both:

• 1.75 times the APC payment amount; and
• APC payment plus the $2,025 fixed-dollar threshold (increased $125 from 2012).

Two-times Rule Violations: Resolutions and Exemptions

During the Hospital Outpatient Payment (HOP) Panel’s (formerly called the APC Panel) February 2012 meeting, information was presented regarding the resource expenditures involved in a direct referral for observation services. CMS analyzed claims data and agreed with the information presented: The resources involved with HCPCS Level II G0379 (*Direct referral for observation services) are very similar to the resources expended for CPT® 99205 (**Level 5 outpatient visit). Based on this data, CMS has reassigned G0379 to APC 0608; this change also resolves the longstanding “two times rule” violation. This change will also provide more appropriate payment when the criteria for composite APC 8002 are not met.

Seventeen APCs have been deemed exemptions from the two-times rule for 2013, based on meeting CMS’ criteria for exceptions (resource homogeneity; clinical homogeneity; hospital outpatient setting utilization; volume of services; opportunity for upcoding and code fragments). A complete discussion of these criteria can be found in the April 7, 2000 OPPS final rule (65 FR 18457 and 18458).

Radioisotope Add-on Payment

The U.S. government and the International Atomic Energy Agency (IAEA) are promoting the conversion of all medical radioisotope production to non-highly enriched uranium (non-HEU) fueled nuclear reactors. This transition is expected to be completed in five years. Alternative methods for producing Tc-99m, such as in cyclotrons, are expected to apply costs in the OPPS that are not accounted for in current or previous claims data. Suppliers of these radioisotopes are expected to pass on the full impact of these costs to hospitals. CMS believes this will create significant payment discrepancies for hospitals due to factors that are over and above the norm.

CMS has created a new HCPCS Level II code, Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on per study dose, to provide an add-on payment to cover additional cost as these sources become available, rather than waiting until the cost is reflected in the claims data. The add-on payment will change as the use becomes more widespread and is included in the rate setting claims data. As these isotopes become more widely used, the cost will fold into the procedure, just as costs for established radiopharmaceutical sources do currently.

Pass-through Payment Changes

Three devices are eligible for pass-through payment in 2013: HCPCS Level II codes C1830 Powered bone marrow biopsy needle; C1840 Lens, intraocular (telescopic); and C1886 Catheter, extravascular tissue ablation, any modality (insertable). Edits will continue for device/procedure reporting and radiopharmaceutical/nuclear medicine procedures.

Reporting of modifiers FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) and FC Partial credit received for replaced device continues to be mandated by CMS for 2013. These modifiers indicate a device was received at no cost or at a discounted cost from the manufacturer and triggers a reduced APC payment. The APCs for which these modifiers apply are listed in Tables 29 and 30 of the OPPS final rule.

Pass-through status for 23 drugs and biologicals expired Dec. 31, 2012. These are listed in Table 31 of the final rule. The cost of two of these drugs is above the packaging threshold, which is $80 for 2013, and separate payment will continue. There are 26 drugs and biologicals designated for pass-through status for 2013. These drugs are listed in Table 32. There are HCPCS Level II code changes for several of these drugs; for example, C9289 is replaced by J9019 Injection, asparaginase (erwinaze), 1000 iu beginning Jan. 1, 2013.

Payment for all separately-payable drugs (with or without pass-trhough status) for 2013 will be made at average sales price (ASP) plus 6 percent. The packaging threshold applies to all classes of drugs, including anticancer therapies.

Number of Inpatient-only Procedures Reduced by One

Despite commenters’ requests that 39 procedures be removed from the list for 2013, only one procedure—CPT® 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical—was removed from the inpatient-only list. CMS noted the procedures not removed from the list were reviewed, and safe performance can be accomplished only in the inpatient setting. Table 45 provides the specifics regarding the single procedure removed, its corresponding CPT® code, and APC assignment.

Supervision for Outpatient Therapeutic Services

CMS extended through 2013 the enforcement of direct supervision for therapeutic services provided in critical access hospitals (CAHs) and small rural hospitals with 100 beds or fewer. In the final rule, CMS notes this will be the final year for the extension.

The HOP Panel received requests for change in supervision levels at both meetings held during 2012. The latest requests were reviewed during the August 2012 meeting and recommendations were made to CMS. Comments were accepted and are in the review process. The final decision will be issued prior to January 2013. The final decisions for change in supervision levels can be found on the CMS website.

Hospital Quality Reporting Program

No new quality measures were established for 2013, and one was removed. CMS policy of reducing payment to hospitals that fail to meet quality reporting requirements will continue at 2 percent for 2013. This reduction extends to the beneficiary and secondary payer payments, as well. CMS will again use a separate conversion factor to apply these reduced payments.

Short Stay Billing Under Part B – Demonstration Project

A new demonstration project has been initiated and is expected to last over the next three years. Titled the “Medicare Part A to Part B Rebilling (AB Rebilling) Demonstration,” this project is in response to hospital comments that staffing restrictions prevent all short stay admissions from being reviewed while the patient is still in-house. Based on the requirements for reporting Condition Code 44, if the patient has been discharged, the hospital has no means to change the status from inpatient to outpatient. Under the demonstration project, when the recovery audit contractor (RAC), Medicare audit contractor (MAC), or Comprehensive Error Rate Testing (CERT) contractor denies the short stay claim on the basis that an inpatient admission was not reasonable and necessary, participating hospitals can rebill the claims under Part B and receive 90 percent of allowable Part B payment for these Part A short stays. Medicare beneficiaries are protected from any adverse impacts based on Part B rebilling.

Other Nuggets

CMS published updates for therapy services in the 2013 Medicare Physician Fee Schedule final rule. Over the past couple of years, CMS has noted they are required to implement a claims-based methodology for therapy services to reform the payment system in the future. To move in that direction, the new guidance initiates the capture of data that has never been reported via a claim. New HCPCS Level II G codes and modifiers have been created to reflect the complexity of service and severity of illness related to beneficiary condition, services furnished, and final outcome. It is imperative that therapy departments review the requirements. Documentation and correct reporting of services are crucial.

*  The definition provided in this article for G0379 is not the HCPCS Level II definition, “Direct admission of patient for hospital observation care.” The definition “Direct referral for observation services” was used purposefully because CMS has repeatedly noted that observation is an OP service and “admission” infers IP admission. CMS has publically stated that “referral” is more appropriate.

** The definition provided in this article for CPT® 99205 is the short definition that hospitals use and will recognize. The full definition is for physicians, not hospitals.

January 1st, 2013

No Comments

Stage 2: EHR Incentives Available If You’re Schooled

Stage 2 Meaningful Use guidelines become effective November 5. To take full advantage of financial incentives available to your practice, knowing what is expected will help.

The Centers for Medicare & Medicaid Services (CMS) announced a final rule after Labor Day specifying the Stage 2 criteria set for eligible professionals, eligible hospitals, and critical access hospitals (CAH) to quality for Medicare and Medicaid electronic health record (EHR) incentive payments. The rule also outlines payment adjustments made if program participants fail to meaningfully use EHR technology. However, the new rules provide a flexible reporting period for 2014 so providers will have sufficient time to adopt or upgrade to the latest technology available in 2014.

CMS said Meaningful Use, which is divided into three stages, affects one out of every five eligible health care professionals.

• Stage 1 sets the basic functionalities electronic health records must include, such as capturing data electronically and providing patients with electronic copies of health information.
• Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information.
• Stage 3 will continue to expand meaningful use objectives to improve health care outcomes.

Remember that if your practice is not a facility, you must meet the measurements or quality for exclusion to 17 core objectives and three to six menu objectives. (If you are a hospital or critical access hospital (CAH), you must meet 16, with three to six menu items.) However, if you are using “2011 Edition Certified EHR Technology,”  you may use it until 2014.  Some new criteria include:

• Patient Engagement. CMS proposed two new core objectives providing patients online access to health information and  secure messaging between patient and provider with measures that require patients to take specific actions  for a provider to achieve meaningful use and receive an EHR incentive payment. For both objectives, the threshold was set at 10 percent of patients. While providers expressed concern, CMS is finalizing the proposed measures with reduced thresholds of 5 percent for both objectives. In addition, CMS introduced exclusions based on availability of broadband in a provider’s practice area.

• Electronic Exchange of Summary of Care Documents. To spur provider commitment to electronic exchange, CMS had initially proposed two ambitious measures for this objective in Stage 2. The first measure required that a provider send a summary of care record for more than 50 percent of transitions of care and referrals. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals. CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR.

Prepare, too, for  clinical quality measure (CQM) guidelines. The rule finalizes that providers must report on nine out of 64 CQMs. All providers must select CQMS from at least three of the six key health care policy domains from the Department of Health & Human Services (HHS) national quality strategy:

• Patient and family engagement
• Patient safety
• Care coordination
• Population and public health
• Efficient use of health care resources
• Clinical processes/effectiveness

For more information about this and hardship exceptions, review the Final Rule, published in the Federal Register Sept. 4.

September 12th, 2012

No Comments