The G-codes are here for payment claims — ready or not
Shelly Mesure, MS, OTR/L
G-coding is a claims-based coding system that CMS plans to “collect and analyze” the data to better understand patient outcomes. It also is meant to be used towards the various conversations surrounding the healthcare reform options floating around.
Many colleagues have asked if I feel the G-coding will affect reimbursement in the future. Well, I just don't know. But, I do know that per the Jimmo lawsuit settled recently, the U.S. District Court of Vermont stated it is unlawful for CMS to deny coverage based on patient outcomes (also known as the “improvement standard”). CMS will be providing further clarification as to the full impact of this lawsuit, but in the meantime must remove the limiting verbiage from the Medicare Benefits Policy Manual and it's retroactive back to early 2011 claims.
So, while we prepare to document and provide accurate information using the new G-codes and C-modifiers, I feel we (as healthcare providers) also have the Jimmo case settled at a perfect time in our industry. I've also been learning that many of our fiscal intermediaries (FIs) have indicated that if the service was provided after Jan. 1, 2013, and the claim is received after July 1, 2013, they will reject the claim if it lacks the corresponding G-codes.
I've been talking with all of my clients to determine when the claims are submitted to the FIs since Medicare only requires a one-year filing requirement. This also means that if your provider submits claims quarterly, then the April, May and June claims will be submitted after July 1 and must include the G-codes.
Lastly, if your provider submits the billing monthly, then all of the claims completed in June will be submitted after July 1. So, we (in therapy) don't have until July 1: We have only until June 1 to be prepared.
There are a lot of operational considerations that must be implemented to ensure compliance with the supervisory visits and reporting systems. So if you haven't started yet, the clock is counting down very quickly to June 1.
Shelly Mesure ("Measure"), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.