Are Medicare G-Codes a Thing of the Past?
The 2012 Middle-Class Tax Relief and Jobs Creation Act (MCTRJCA) amended the Social Security Act to require a claims-based data collection system for outpatient therapy services. This included physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services. The system collects data on Medicare beneficiary function during the course of therapy services to better understand beneficiary conditions, outcomes, and expenditures. Beneficiary function information was reported using 42 non-payable functional G-codes and seven severity/ complexity modifiers on claims for PT, OT, and SLP services.
PT/OT/SLP practitioners were required to assess a patient and assign a specific severity/complexity modifier utilizing the Functional Limitation Reporting (FLR) G codes. Due to CY 2019 Physician Fee Schedule (PFS) rulemaking, effective for dates of service on or after January 1, 2019, Medicare no longer requires the functional reporting of non-payable HCPCS G-codes and severity modifiers − adopted to implement section 3005(g) of MCTRJCA − on claims for therapy services. The services affected by this change were 97XXX and associated HCPCS code (G0283); these services are part of the therapy cap.
So, what does that mean for chiropractic G-code reporting around functional outcomes and pain? As chiropractors, we do not fall under the therapy cap because these PT codes are statutorily excluded services. When we dug deeper into the notices released by Medicare, we found that the spinal CMT codes were not listed as part of this change.
Medicare further states that the G-Codes were quality data codes that rehab therapy providers – including eligible physical therapists, occupational therapists, and speech/language pathologists – included on their Medicare claim forms to fulfill requirements for Functional Limitation Reporting (FLR). The FLR code is not the same as the FOA and pain assessment G Codes that DCs utilize as part of quality reporting measures.
What’s the Same?
The reporting for Functional Outcome Assessments (FOA) and pain have not changed for the chiropractic community. The change in January was for therapy services provided by PT, OT, SLP providers. Per Medicare, chiropractors are performing manipulative services. If you are required to participate with MIPS or are voluntarily reporting, please continue to use the appropriate G codes based on FOA/pain as applicable.
When reporting for Quality ID#182 (NQF 2624), Functional Outcome Assessment, we find this is still a relative 2019 MIPS Clinical Quality Measure (CQMS). NUMERATOR NOTE: The intent of this measure is for a functional outcome assessment tool to be utilized at a minimum of every 30 days, but reporting is required at each visit due to coding and billing rules. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the appropriate numerator quality data code should be used for reporting purposes.
Am I Required to Participate?
To view your Quality Payment Program (QPP) status and MIPS reporting requirements, visit the QPP website at qpp.cms.gov/participation-lookup. Eligible physicians who fail to report data under Medicare’s 2019 Quality Payment Program (QPP) will be subject to a 7% penalty in 2021. That penalty will rise to 9% the following year. The current thresholds for Mandatory participation are:
- Dollar amount – $90,000 in covered professional services under the Physician Fee Schedule (PFS) (this means AT modifier worthy CMT codes) and;
- Number of beneficiaries – 200 Medicare Part B beneficiaries and;
- Number of services (New) – 200 covered professional services under the PFS (this means AT modifier worthy CMT codes)
If you are not required to participate but choose to voluntarily submit the Quality Reporting G codes, you will not see a positive increase to reimbursements unless you are Opt-In Eligible. To be considered Opt-In Eligible you must exceed one or two (but not all three) of the low-volume threshold (LVT) criteria (allowed charges, Medicare patients, and covered services), and are not otherwise exempt, during either segment of the MIPS determination period.
Benefits of Electing to Opt-In
So, in plain English, this means that if you DO NOT meet all three of the criteria and elect to opt-in, you will:
- Be considered a MIPS eligible clinician and be required to report,
- Receive performance feedback,
- Receive a MIPS payment adjustment (positive, negative, or neutral),
- Be eligible to have your data published on Physician Compare, and;
- Be assessed in the same way as MIPS eligible clinicians who are required to participate in MIPS and are therefore automatically included.
Wrapping it Up
So, the overall quick answer is this: Yes, chiropractors still report quality measures utilizing the G codes relative to FOA and Pain assessments, if you choose to opt-in, or if you meet or exceed the threshold.
Whether you are required to report, are opt-in eligible, or simply voluntarily report, we think it’s a good idea to use FOAs in your practice, anyway. Standardized outcome assessments, questionnaires or tools are a vital part of evidence-based practice. Utilization of the appropriate outcome assessment, questionnaires, and tools enhances clinical practice by:
- identifying and quantifying body function and structure limitations
- formulating evaluation, diagnosis, and prognosis
- forming the plan of care
- assisting in evaluating the patient progress towards the goals and validating the benefits of treatment
- improving communication between client, clinician, and third-party payer
- assisting in improving the documentation of care provided.
If you need assistance, never hesitate to reach out to KMC University for assistance.
Call (855) 832-6562 now or click to schedule a 15-minute Solution Consultation at your convenience.
Yvette Noel is the Membership Services Manager and conference speaker with KMC University. She is a Certified Professional Compliance Officer (CPCO). She has served the chiropractic community for 13 years and has worked in the medical field since 1988. Through this experience, she has continued to develop her skills of medical coding and billing. Before coming to KMC University, she managed a very successful Chiropractic and Occupational Health business. She remains very passionate about KMC University and takes much pleasure in helping members with their documentation, reimbursement, and compliance needs.