Functional Limitation Reporting Glitches: Past and Present

Written by Tom Ambury on March 25, 2014

Today’s post comes from Tom Ambury, PT and compliance officer at PT Compliance Group

At the Beginning

On January 1, 2013, the Centers for Medicare and Medicaid Services (CMS) put functional limitation reporting requirements into effect—with a six month practice period—for PTs, OTs, and SLPs. As of July 1, 2013, all rehab therapists must report FLR—using G-Codes, severity modifiers, and therapy modifiers—for all Medicare Part B patients at the initial evaluation, progress note (at minimum every ten visits), re-evaluation (if applicable), and discharge in order to receive reimbursement for their services. Additionally, documentation must support the G-codes and clearly demonstrate how the provider used his or her clinical judgment in conjunction with an outcome measurement tool to arrive at a reporting decision.

The October Glitch

As you may remember, there was quite a bit of concern as to how the reporting would go on July 1. But despite a few bumps here and there, things began pretty smoothly for providers who were well prepared to address the new requirements. That is, until October—when, without warning, providers began receiving claim rejections from their MACs.

Apparently, some of the MACs were not prepared to begin processing the new FLR codes on July 1, so they continued to process the claims without them—until October. As a result, they counted the first visit on or after October 1 as visit number-one for FLR purposes. Thus, if the claim did not contain FLR data, which in many cases it didn’t—nor should it have—the MAC rejected the claim.

The January Glitch

We got through the October glitch with a few scratches—maybe a bruise or two—but it seemed we were in the clear. Then January rolled around, and with it came a whole new batch of claim rejections. This time, the sheer number of codes on a single claim were to blame. Providers who were completing PQRS via claims-based reporting to earn the incentive were reporting on up to nine quality measures, which, when you include CPT codes and FLR codes, is an awful lot of codes—especially because Medicare only allows six lines and up to six different codes on a claim. When a claim contains more than six lines and/or codes, Medicare splits the claim into two. If the FLR codes end up on a different claim than the CPT ones, Medicare rejects the claim.

What Now?

As of March 2014, some providers are still receiving claim rejections because of the split claim issue. However, providers are still required to complete FLR, so Medicare is continuing to modify the system to address this issue and avoid future ones. That said, here’s what you can do on your end to help the situation:

  • Continue to report FLR as required at an eligible patient’s initial evaluation, re-evaluation, progress report (on or before every tenth visit), and discharge.
  • Check your documentation regularly to ensure you’re meeting the FLR requirements as this is a condition of payment.
  • Reorder the codes on your claims so that the FLR codes immediately follow the first CPT code.
  • If you receive a claim rejection, check the claim ordering and adjust if necessary. Also, look for dates of service on which you performed an evaluation to see if those are being denied (as opposed to visits on which you did not perform an evaluation).
  • If you continue to receive claim denials, report the issue to your professional organization (the APTA is tracking these issues and reporting them to CMS) and/or directly to CMS.
  • Considering seeking professional help. My company, PT Compliance Group, can audit your charts using our updated ChartSafe tool, which tracks whether or not you’re meeting the FLR requirements. We also can work with you to identify the reasons you’re receiving rejections and help you navigate the appeal process.

If you have any questions about functional limitation reporting, claim rejections, or how we can help, please contact me at questions@ptcompliancegroup.com or 888-680-7688.