functional limitation reporting patient example

With July 1 right around the corner, we know what’s on your mind: functional limitation reporting (FLR). That’s why we’ve dedicated (almost) this entire month to the ins and outs of G-codes and severity modifiers. But perhaps our discussions have been a little too theoretical for your liking. (We know FLR is one spicy meatball.) If that’s the case, don’t fret. Here’s a more concrete patient example to help solidify your understanding of CMS’s latest regulation. First, some handy dandy references for said example.


References

G-Codes:

Mobility: Walking & Moving Around

  • G8978 Mobility: walking and moving around functional limitation, current status, at therapy episode outset, and at reporting intervals.
  • G8979 Mobility: walking and moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting.
  • G8980 Mobility: walking and moving around functional limitation, discharge status at discharge from therapy or to end reporting.

Other PT/OT Primary Functional Limitation

  • G8990: Other physical or occupational primary functional limitation, current status, at therapy episode outset, and at reporting intervals.
  • G8991 Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting.
  • G8992 Other physical or occupational primary functional limitation, discharge status at discharge from therapy or to end reporting.

Modifiers:

severity modifiers


Example

Your new patient “Will” has sought your physical therapy services following a total hip replacement. For this example, we can establish Will’s primary functional limitation as Mobility: Walking & Moving Around. Because this is Will’s initial examination, the corresponding G-code is G8978. Now for the modifier. Appropriate to Will’s current condition, you’re going to select the lower extremity functional scale—an outcome measurement test (or one like it) that you should be performing on Will even without this new mandate. Will scores a 5; based on the test scoring rules that means he is at 6.25% of maximal function—or 93.75% impairment—which corresponds to modifier CM. So, Will’s current status on his initial examination would be G8978 CM GP. You’d want to make sure that this code appears on the claim you submit to billing for the initial exam.

Now, let’s tackle his goal. You’ll select G8979, the code under Mobility: Walking & Moving Around that applies to projected goal status, and assign to it the CI modifier because you believe that by the end of treatment Will will improve to at least 1% but less than 20% impairment. You’d want to make sure that G8979 CI GP also appears on the claim you submit to billing for the initial exam.

At the tenth visit, Will’s G-code remains the same (G8978) and you perform the same outcome measurement tool. As a result of your treatment, Will’s score improves to an 18; this means he’s at 22.5% of maximal function—or 77.5% impairment—which corresponds to modifier CL. So, Will’s current status on his tenth visit is G8978 CL GP. Unless there is any change to your goal for Will, his projected goal status code remains the same at G8979 CI GP. You’d want to make sure that G8978 CL GP and G8979 CI GP appear on the billing claim you submit to Medicare for this Progress Note visit. You may not bill the re-evaluation code 97002 just for submitting these codes; you may only bill 97002 if this is truly a re-evaluation.

On the 20th visit, Will’s progress is outstanding, and he scores a 75 on the lower extremity functional scale; this means he’s at 93.75% of maximal function—or 6.25% impairment—which corresponds to modifier CI. Will has met his goal so you discharge his primary functional limitation with G-code G8980, the code under Mobility: Walking & Moving Around that applies to discharge status (G8980 CI GP). The projected goal status code remains the same at G8979 CI GP. These codes will again appear on the billing claim for this date of service.

Unless you identify a new primary functional limitation at this point, you must discharge Will from therapy. In this case, let’s say that Will is also experiencing wound healing capacity limitation. This doesn’t fall under any of the other functional limitation categories, and this is the first time you are assessing this limitation, so you select G8990, Other PT/OT Primary Functional Limitation, as Will’s new primary functional limitation. Based on your assessment, you decide to perform the South West Regional Wound Care Toolkit and determine he has a 50% wound healing limitation, which corresponds to modifier CK. Thus, Will’s new G-code is G8990 CK GP. This would appear on the billing claim on this 21st visit date of service. You can now continue to see Will with wound care as your primary limitation. Treatment and documentation of treatment must now reflect this primary limitation. As treatment continues for Will, you will repeat the steps listed above at the 31st visit, 41st visit, etc., through the discharge of the patient.


Want an FLR easy button? If you’re a WebPT Member, you’ve got one. On May 17, WebPT is rolling out a fully integrated functional limitation reporting solution. Register here for our WebPT + FLR webinar on May 20 to see how easy it is to complete FLR within your WebPT documentation. Not yet a Member? Schedule your no-hassle demo today to learn more.