Appropriate Reporting of G-Codes & C-Modifiers by Therapists Who Treat Chronic Wounds

  Passed in 2012, the Middle Class Tax Relief & Jobs Creation Act requires the Centers for Medicare & Medicaid Services (CMS) to implement a data collection system for outpatient therapy services provided to Medicare beneficiaries. The process is required to collect data on beneficiary function during the course of therapy services in order to provide a better understanding of beneficiary conditions, outcomes, and expenditures. The goal is for this data to be used to develop a new payment system for outpatient therapy services, which includes physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP). The process that was developed is termed “functional limitation reporting” (FLR) and consists of “G-codes” and severity modifiers (“C-modifiers”), which will be explained in further detail within this article. As of July 1, 2013, any therapy service claims submitted without the applicable G-codes and modifiers are returned as unpaid.

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Definition of FLR

  FLR applies to any practice setting that provides outpatient PT/OT/SLP services, including all Medicare Part B outpatient clinics, hospital-based outpatient departments, “observation” patients in the inpatient setting, rehabilitation agencies, home health agencies, comprehensive outpatient rehabilitation facilities, acute care hospitals, critical access hospitals, skilled nursing facilities, and private practices. They also apply to any therapy services furnished incident to the service of a physician and certain non-physician practitioners, including nurse practitioners, certified nurse specialists, and physician assistants.¹ Codes are also required for medical/Medicare patients when Medicare is the secondary insurance.

Definition of G-codes

  G-codes are nonpayable codes used to report a patient’s functional limitations and are organized in sets that describe patient status at different points during treatment. Only one functional limitation area based on the related plan of care is reported at a time. If goals for that limitation are met and therapy services are still needed, a second functional code is required to address the remaining functional limitation. Common functional limitation areas reported by therapists include:
    • mobility (walking and moving around);
    • changing and maintaining body position;
    • carrying, moving, and handling objects;
    • self-care; and
    • other PT/OT/SLP.

  CMS has directed those therapists performing wound management interventions, including lymphedema management, to select the “Other PT/OT/SLP” G-code set when the primary interventions are specifically directed at wound healing. Each G-code set includes three codes used to describe the patient’s current status, projected goal status, and discharge status (see Table 1).

  Definitions of the G-codes with the correlating numbers are used to define patient status at the time of reporting. Reporting of the G-codes is required at specific intervals in the patient’s care (see Table 2):
    • evaluation;
    • end of each progress/functional reporting period (on or before the 10th treatment day);
    • re-evaluation;
    • end of the initial G-code reporting when additional therapy services are needed (ie, the primary functional limitation has resolved, but continued care is still required);
    • beginning of a new G-code; and
    • discharge.

  When selecting a G-code, the therapist selects the G-code category that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment. The primary limitation should support the need for skilled therapy services. Only one primary functional limitation is reported at a time, so the one that reflects the predominant limitation being addressed by PT/OT/SLP should be selected. If the patient has more than one functional limitation, the therapist determines the primary limitation. This decision should take into consideration the area that is the most clinically relevant to a successful outcome for the patient, the area that is the greatest priority for the patient, and the area that may respond the most quickly to treatment and/or demonstrate the greatest functional progress. The goals set by the PT/OT/SLP must be consistent with the G-codes and severity modifiers selected for the patient.

Severity/Complexity Modifiers

  A modifier is used with each G-code to report the severity/complexity for that functional limitation (see Table 3). Severity/complexity modifiers estimate the degree of impairment, limitation, or restriction as determined by the therapist.

  Formalized testing measures and/or functional assessment tools are recommended for the selection of the appropriate severity/complexity modifier and are included in the initial evaluation. The severity modifier that most accurately describes the patient’s level of impairment is selected based upon the test results and the therapist’s judgment. The tests may be specific functional tests (eg, dynamic gait index, self-selected walking speed [SSWS], Timed Up and Go [TUG], Outpatient Physical Therapy Improvement in Movement Assessment Log) or quality-of-life surveys (eg, SF-36, burn specific health scale). This determination requires the use of clinical judgment – no single tool will be used alone to assign a severity modifier. The documentation needs to include how the severity/complexity modifier was determined so that the same process can be reproduced for later reporting intervals. If there is a situation in which therapy is not intended to treat a functional limitation (eg, the wound does not affect patient function), CMS recommends using the modifier “CH” (0% impairment). In situations where functional improvement for the patient is expected to be limited (or not expected at all), the severity modifier used to report current status would also be used to report projected goal status. If a patient is only seen for an evaluation and additional therapy services are not medically necessary or future services will be provided by a different provider, all three G-codes and modifiers are reported for that single date of service (current status, projected goal status, and discharge status). It is important to note that the percent of impairment is only that impairment caused by or influenced by the wound. Also, it is not a reflection of the impairment of the integumentary system. (See the case studies within this article.)

  Patients being seen under observation status or in an emergency department are receiving outpatient services and, as such, FLR pertains to these patients. If a patient were schedule to be admitted and was then changed to observation status, an addendum could be placed in the chart to determine G-codes as long as formalized testing/functional assessments were already completed and documented. If an observation patient is admitted as an inpatient, functional limitation reporting no longer applies.

  If a patient is discharged unexpectedly, discharge G-codes are not required, but if the patient is readmitted within 60 days he/she must continue with the FLR that was initiated until discharge G-codes and modifiers are submitted.

APTA Task Force on Wound & Integumentary Functional Limitations

  The American Physical Therapy Association (APTA) has initiated a task force to address FLR as it pertains to wounds and the integumentary system. The task force objectives include clarifying the CMS instructions on the use of functional limitation documentation for patients living with wounds, assessing current practice of clinicians performing wound management, researching tools that address the impact of wounds on function, and researching tools that measure wound healing progress. At present, this task force is appraising the tools that were collected relating to function and wound healing. Once this process is completed, recommendations will be given regarding optimal tools to use. The task force is also developing wound care-specific case studies to share with CMS as examples of appropriate FLR for patients living with wounds.

Case Studies Featuring Functional Reporting

  1) Diabetic Foot Ulcer (DFU)
  61-year-old male with a 20-year history of diabetes mellitus. He manages the diabetes with oral hypoglycemic agents (sulfonylureas); however, he frequently has blood glucose levels between 180 and 250 mg/dL due to poor control. He presents to clinic with an ulcer on the right plantar first metatarsal head measuring 2 cm x 3 cm x 2.5 cm. States he noticed the wound when he changed his socks and observed the drainage.

  Review of systems reveals the following:
    • loss of protective sensation on the plantar surface of bilateral feet;
    • hip and knee range of motion (ROM) within functional limits;
    • hip strength grossly 4-/5, knee flexion and extension 4-/5, ankle dorsiflexion and plantarflexion 3/5 within the active ROM;
    • right ankle 15o active ROM, left ankle 25o active ROM;
    • right ankle proprioception moderately impaired;
    • 4+ dorsalis pedis and posterior tibialis pulses bilaterally; and
    • mild hypertension (140/80) controlled with Valsartan.

  Wound assessment reveals a moist wound base with dusky granulation tissue and a ring of hyperkeratotic tissue at the wound margin that extends into the periwound area. Drainage appears to be light serosanguineous exudate with no discernable odor after cleansing. Bone is neither visible nor directly palpable. Wagner classification is Grade I; University of Texas Classification System of DFUs is B III. He does not report any pain or discomfort in his right foot.

  Functional assessment included the following:
    • TUG = 8.7 seconds;
    • 5 times sit-to-stand test = 12 seconds; and
    • Tinetti Assessment Tool = 20 (moderate risk for falls).

  Based on the assessment, the initial G-codes and C-modifiers reported were:
    • G-8990 (other PT/OT primary current status) and “CJ” (at least 20%, but < 40% impairment) and
    • G-8991 (other PT/OT primary goal status) and “CI” (at least 1%, but < 20% impairment).

  Treatment plan included the following: selective debridement, moisture-retentive wound dressings, offloading device, exercise to increase ankle ROM and activate the gastrocsoleus group (venous pump), and gait training with single point cane to improve balance.

  At treatment No. 10, functional tests would be repeated and wound care continued:
    • G-8990, “CI” impairment with impairment of 10%;
    • G-8991, “CH” with 0% impairment being the goal.

  At the end of 15 treatments, wound has resolved; however, patient meets the requirements for customized shoes with accommodative inserts:
    • G-8991, CI

  2) Venous Wound
  70-year-old female living with a wound on the right medial lower leg in the gaiter area, measuring 6.2 cm x 4.5 cm x 0.3 cm at 8 months duration. Medical history includes right total hip replacement three years ago complicated by a deep vein thrombosis during the rehabilitation period. In addition, she had a fall two years ago with a mild right ankle sprain. Medications now include 81 mg of aspirin daily, vitamin complex, and 2-3 nonsteroidal anti-inflammatory capsules daily for joint pain. Her current pain at the wound site is described as 4/10, “burning sensation that increases with prolonged standing.”

  Review of systems reveals the following:
    • no cardiopulmonary impairments;
    • 2+ dorsalis pedis and posterior tibialis pulses;
    • normal ankle ROM on the left, 20o total active ROM on the right;
    • moderate hemosiderin stains on the right lower leg;
    • mild edema on the right as compared to the left (1-2 cm difference throughout);
    • hip and knee ROM within functional limits;
    • hip strength grossly 4-/5, knee flexion and extension 4/5, ankle dorsiflexion and plantarflexion 3+/5 within the active ROM; and
    • intact sensation throughout lower leg and foot.

  Wound assessment, in addition to the size stated above, included irregular edges with minimal serosanguineous drainage (however, patient had applied clean dry gauze to the wound bed just prior to coming into therapy), 50% of the wound with adhered fibrous yellow tissue, and 50% nongranulated red subcutaneous tissue. Bates-Jensen Wound Assessment Tool (BWAT) score was 43/60.

  Functional assessment included the following:
    • interpreted SSWS = 0.63 meters per second;
    • TUG = 15 seconds; and
    • 5 times sit-to-stand test = 18 seconds.

  Based on the assessment, the initial G-codes and C-modifiers reported were:
    • G-8990 (other PT/OT primary current status) and “CK” (40% impairment); and
    • G-8991 (other PT/OT primary goal status) and “CI” (based on the expectation that by the end of 10 treatments the patient’s function will improve and impairment will decrease to < 20%).

  Treatment plan included the following: selective debridement; noncontact, low-frequency ultrasound; absorbent dressings; multilayer compression therapy; exercise to increase ankle ROM and activate the gastrocsoleus group (venous pump); and gait training to improve heel-toe sequence and increase venous pump efficiency during gait. At treatment No. 10, the BWAT and functional tests would be repeated and, assuming that wound care was still the primary focus of treatment and function had improved, the following codes would be reported:
    • G-8990, “CJ” with impairment of 25%; and
    • G-8991, “CH” with 0% impairment being the goal.

  At the end of 15 treatments, if the wound required only dressing and compression changes, but the patient still needed functional training, the codes would be as follows:
    • G-8991, “CH” with 0% impairment (the goal); and
    • G-8992, “CI” with 15% impairment based on a repeat of the three functional assessments.

  At this time, the “other” (wound care goal) has been discharged and the G-code would change to the following:
    • G-8978 (mobility current status) and “CI” with 15% impairment; and
    • G-8979 (mobility goal status) and “CH” with 0% impairment.

  When the patient is discharged from therapy services, the codes would be as follows:
    • G-8979 (mobility goal status) and “CH” with 0% impairment; and
    • G-8980 (mobility discharge status) and “CH” with 0% impairment (if justified by reassessments).

Summary

  Although it adds more time and effort to documentation for patients covered by Medicare, the FLR does give rehab clinicians the opportunity and the motivation to further incorporate functional assessment and interventions into their treatment of wound patients. In doing so, therapists can demonstrate to CMS the unique and beneficial services that are provided to patients in addition to wound care itself as well as providing the opportunity to assess and reflect upon individual practice.

  Heather Hettrick is associate professor, department of physical therapy, Nova Southeastern University, Fort Lauderdale, FL. Stephanie Woelfel-Dyess is instructor of clinical physical therapy, division of biokinesiology and physical therapy, University of Southern California, Los Angeles. Rose Hamm is assistant professor of clinical physical therapy, division of biokinesiology and physical therapy, University of Southern California, Los Angeles.

Reference

1. 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. Department of Health and Human Services, Center for Medicare & Medicaid Services. MLN Matters: Information for Medicare Fee for Service Health Care Professionals. Number MM8005. Released Nov. 30, 2012.

Resources

1. American Physical Therapy Association. Functional limitation reporting under Medicare. Accessed online: www.apta.org/payment/medicare/codingbilling/functionallimitation/

2. Centers for Medicare & Medicaid Services. CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 2622.

3. Haan J. Task force on wound and integumentary functional limitations. Clinical Electrophysiology & Wound Management Section Newsletter. 2014;28(2):6.