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Rehabilitation professionals have been presented with significant new challenges since new functional G-code requirements became effective July 1. Those who use them wrong could lose big. Various experts describe here how to best deal with them and win.

Verify a patient’s payer source before treatment begins whenever possible.

“It complicates things if you need to go back and review documentation to establish appropriate G-coding on patients not believed to have Medicare B as a primary or secondary payer after therapy is already initiated,” notes Matt Sivret, division vice president of clinical operations for RehabCare.

He also recommends using established objective tests, measures and familiar functional outcomes to crosswalk to the G-code/modifier scale. 

Without exception, therapists responsible for selecting, documenting or reporting G-codes and modifiers must be well educated on Centers for Medicare & Medicaid Services requirements, says Margaret Kopp, a regional director of clinical services for Select Medical Rehabilitation Services in Pennsylvania.

Start with firm understanding of the 42 G-codes and their short descriptors, as well as the seven-point severity modifier scale.

“Ensure a system, whether manual or software, that alerts the therapist when to apply the G-codes and modifiers — at the outset of care, on or before the progress reporting tenth visit, at discharge or at discontinuation of the functional limitation and when starting an additional/new functional limitation,” Kopp says.

Many experts, including Sivret and Kopp, emphasize that there must be a lot of effective communication between therapists and the business office. Accuracy of claims must be painstakingly checked.

In addition, therapy service logs should be provided to billing offices, Kopp says.

Providers should prepare properly for interruption and resumption of therapy. For example, if a patient unexpectedly is discharged but then resumes therapy within 60 days, functional limitation reporting would have to continue with the original G-code, remind Kopp and Mary Pidich, director of education and compliance for IL-based Select Rehabilitation.

Pidich also recommends providing therapists with a “cheat sheet” for “Unique Functional Reporting Scenarios.” This would include for one-time therapy visits and for reporting evaluative procedures for a different functional limitation than the one currently being reported.

Therapists should not wait until the therapy assessment/progress report/discharge summary is completed to report G-codes and severity modifiers, stresses Gina Tomcsik, director of compliance with Functional Pathways.

“Cue cards for therapists to reference are extremely beneficial,” she adds.

Partner with the therapy provider and together develop “a triple-check process to ensure the G-codes and severity modifiers are appropriately reported prior to submission of claims,” Tomcsik says. “This will decrease provider workflow burden with any potential rejected therapy claims.”

The most important thing to do is ensure that entire rehab teams are on the same page as far as aligning the specific scores on tests and measures with the G-codes, says Sharon Brown, vice president — operations for SYNERTX Rehab.

“You want to make sure there is as much consistency between how team members should measure the same patient at the same time,” she notes. “We’ve done a lot of work to tie our most commonly used tests and measures nationally to consistent G-codes, then educate all of our teams to drive greater, consistent utilization.”

Educating an entire workforce on new functional coding requirements that do not directly tie to a functional outcome measure has not been easy, says John Calcavecchia, vice president of business development for Preferred Therapy Solutions. 

“This education must be ongoing to ensure compliance and attempt to improve reliability and validity,” he notes. 

Mistakes to Avoid

Risking billing rejections by allowing inconsistencies to exist among staff members’ assessments.

Not fostering continual and thorough communication between therapy and billing departments.

Not being prepared for resumption of therapy within 60 days of an unplanned discharge.