It’s been more than a year since the Centers for Medicare & Medicaid Services (CMS) began requiring that all eligible professionals—including outpatient rehab therapy providers—submit functional limitation reporting (FLR) data as a condition of reimbursement. And with all of the G-codes that physical therapists, occupational therapists, and speech-language pathologists have submitted since last July, you’d think it would be pretty smooth sailing by now. But as you’re probably well aware, that’s not exactly the case. In fact, there’s still a handful of tricky FLR scenarios causing plenty of grief—and denials—for rehab therapists. Here’s a quick guide on how to handle them to make sure you get paid.
Scenario 1: A patient stops attending therapy but returns within 60 days to receive treatment for the same functional limitation.
Solution: This one is actually pretty simple. If a patient stops attending therapy midway through his or her treatment but returns within 60 days—or about two months—to address the same functional limitation, there’s no need to complete a discharge note or submit discharge FLR data on the patient’s first return visit. Instead, in this situation you would resume treating the patient—and reporting on his or her primary functional limitation—as if he or she had never left.
Scenario 2: A patient stops attending therapy but returns within 60 days to receive treatment for a different functional limitation.
Solution: This situation also is fairly straightforward. If a patient self-discharges but returns within 60 days to receive treatment for a new, different functional limitation, you should not begin reporting on the new functional limitation during the patient’s first visit back to therapy. Instead, you must submit the discharge data for the old primary functional limitation during that visit. Then, on the patient’s next (that is, second) visit back, you would begin reporting FLR data for the new limitation.
Scenario 3: A patient stops attending therapy and returns after 60 or more days to receive treatment for his or her original functional limitation or a new functional limitation.
Solution: Because Medicare automatically discharges a therapy reporting episode 60 days after the last date of service on record, there’s no need to complete any type of discharge reporting in the event that a patient self-discharges and returns after two or more months. Essentially, a patient in this situation has a clean slate as far as FLR goes, and you would not need to submit any additional G-codes or severity modifiers for the original primary functional limitation. Instead, you would proceed as if you were treating a new patient: perform an initial evaluation and start fresh with functional limitation reporting.
Scenario 4: A patient who is currently seeing you for therapy treatment presents with a second diagnosis that is unrelated to the original one.
Solution: This is where things get a bit hairy. If you’re already treating a patient for one diagnosis—and you’ve already established a primary functional limitation—and the patient presents with a new, unrelated diagnosis mid-treatment, you basically have three possible courses of action:
1. You can combine both issues into a single case.
If you go this route, then you will perform a re-examination, add the second diagnosis, and continue to see the patient for both issues under the same case. The only hitch is that Medicare will only accept functional limitation reporting data for one primary functional limitation at a time. That means you’ll need to decide which diagnosis represents the patient’s true primary functional limitation.
If you believe the original primary functional limitation should remain, then upon re-exam you will:
- Complete FLR for the new diagnosis as a one-time visit (i.e., submit three sets of G-codes and severity modifiers for the current status, goal status, and discharge status).
- Update the current and goal statuses for the original limitation by submitting two additional sets of G-codes and severity modifiers.
If instead you believe the functional limitation associated with the new diagnosis best represents the patient’s primary functional limitation, then you’ll need to:
- Submit discharge FLR data for the original functional limitation on the claim for the re-exam.
- Start FLR for the new primary functional limitation on the next date of service.
2. You can treat the cases separately on separate days.
If you decide to treat the cases separately, then each visit must be dedicated to the treatment of only one diagnosis. In this situation, you must choose one of the cases to be the “reporting case”—that is, the case that represents the patient’s true primary functional limitation and the one for which you will submit FLR data.
- If you decide the original case should be the reporting case, then you will complete functional limitation reporting for the new case as a one-time visit (i.e., submit three sets of G-codes and severity modifiers for the current status, goal status, and discharge status).
- Alternatively, if you believe the new case should be the reporting case, then you will report discharge FLR data for the original case on the initial evaluation for the new case. You will then start FLR for the new case on the next date of service.
In both of the scenarios above, you must weave elements of your treatment plan for the reporting case into the non-reporting case to ensure that the patient achieves the best possible outcome.
To better explain this somewhat confusing situation, here’s an example:
PT Jane is treating Patient John for back pain and completing FLR for the primary functional limitation Mobility: Walking & Moving Around. We’ll call this Case 1. A couple of weeks later, John comes in to Jane’s office with a new diagnosis for shoulder pain, which we’ll call Case 2. When Jane completes the initial evaluation for Case 2, she decides John’s true primary functional limitation should be Carrying, Moving & Handling Objects. So on the claim for the initial evaluation, she reports the discharge FLR data for the original primary functional limitation (Mobility: Walking & Moving Around). Then, on the next date of service—regardless of which case that visit is associated with—Jane will submit FLR data for the new primary functional limitation (Carrying, Moving & Handling Objects). At that point, the ten-visit count begins, and the count is shared between cases. That means Jane must complete a progress note with FLR data on or before John’s tenth visit—regardless of which case that visit falls under.
If instead Jane believes that John’s original primary functional limitation (Mobility: Walking & Moving Around) should remain, then she should submit FLR data for the limitation associated with the second case (Carrying, Moving & Handling Objects) on the initial evaluation for that case as if it were a one-time visit (i.e., by submitting three sets of G-codes and severity modifiers to reflect the current status, goal status, and discharge status). At that point, she will cease FLR for the second case and will continue to complete FLR as normal for the original case.
3. You and another therapist can treat both cases separately.
In some cases, you may believe it’s in the patient’s best interest to receive treatment for the second case from another physical therapist in your clinic. If that’s the case, then both physical therapists should collaborate to decide which diagnosis best represents the patient’s primary functional limitation. If you both conclude that the patient’s true primary functional limitation is the one associated with the original diagnosis, then you will continue to submit FLR data as normal, and your colleague will report FLR data for the second limitation as a one-time visit (i.e., by submitting three sets of G-codes and severity modifiers to reflect the current status, goal status, and discharge status).
On the other hand, if you both determine that the new diagnosis represents the patient’s primary functional limitation, the other therapist will:
- Submit discharge FLR data for the original limitation on the initial evaluation for the new case.
- Start FLR for the new diagnosis on the next date of service.
Regardless of which case becomes the reporting case, each case’s plan of care should incorporate treatment elements aimed at the patient’s primary functional limitation. Why the emphasis on collaboration? Well, think about it this way: Even though the patient has two separate diagnoses, two separate cases, and two separate physical therapists, Medicare sees only one patient with one primary functional limitation and one visit count. Thus, the patient likely will reach his or her tenth visit before either therapist has seen the patient ten times. So it’s crucial that he or she is progressing toward his or her functional limitation goals on every single visit—not just the ones for the reporting case. Here’s an example to better explain this situation:
PT Jane is treating Patient John for knee pain (Case 1), and his primary functional limitation is Mobility: Walking & Moving Around. A couple of weeks later, John begins seeing PT Bob—another therapist in the same clinic—for back pain (Case 2). After discussing John’s situation, Jane and Bob agree that John’s primary functional limitation is actually the one associated with the new case: Moving & Handling Objects. So, on the initial evaluation for Case 2, Bob submits discharge FLR data for the original primary functional limitation (Mobility: Walking & Moving Around). Then, whichever therapist sees John next will be responsible for starting FLR for the new primary functional limitation. At that point, the ten-visit count begins, and that count is shared between Bob and Jane. So one of the therapists will need to submit FLR data on or before John’s tenth visit—otherwise, no claims submitted after that date will be reimbursed. For that reason, Bob and Jane might want to structure John’s appointment schedule so that Bob—who is providing treatment for the reporting case—completes all FLR progress notes.
Scenario 5: You are treating a patient for one case, and another therapist in your clinic who has a different specialty (e.g., you’re a PT and he or she is an OT) is treating the same patient for a second case.
Solution: Complete FLR separately and independently of one another. When a patient is receiving treatment in two different disciplines—such as physical therapy and occupational therapy—Medicare tracks FLR for each discipline separately. Thus, the patient can simultaneously have one primary functional limitation for OT and another primary functional limitation for PT.
Scenario 6: You’re doing everything right, but you’re still receiving denials for improper functional limitation reporting.
Solution: There are still a few kinks in Medicare’s system for tracking FLR. So if you’re positive you’re doing everything correctly, but you continue to receive denials from Medicare, here’s what you can do:
- Contact your local MAC and check their website regularly for updated FLR guidance.
- If you belong to the APTA, submit a complaint form at apta.com/FLR/ComplaintForm. APTA representatives have been meeting with CMS officials on a fairly regular basis to discuss FLR issues and develop solutions, and the more information you provide them, the better they can represent you in those discussions. Also, be sure to check the APTA website for updated FLR news.
- Contact your EMR. They should have solutions in place for all of these tricky scenarios, and they also should be able to help you understand them.
Have you been affected by denials in any of the wonky scenarios discussed above? What did you do? Share your experiences in the comment section below.