Today's blog post comes from WebPT Senior Writer Charlotte Bohnett, contributing writer Erica Cohen, and WebPT Co-Founder Heidi Jannenga, PT.

Monday and Tuesday we hosted webinars on functional limitation reporting. We got tons of great questions. Here are the most frequently asked ones:

The Basics

What is functional limitation reporting?

Beginning July 1, 2013, CMS is requiring that you complete functional limitation reporting (FLR) on all Medicare part B patients in order to receive reimbursement for your services. Essentially, FLR is a type of reporting focused on the progress of the patient through measurable goals, and supporting documentation is required for reimbursement.

Who created FLR?

CMS developed functional limitation reporting as part of the Middle Class Tax Relief Act of 2012, which mandated the collection of the following information regarding the beneficiaries on the claim form: function and condition, therapy services furnished, and outcomes achieved on patient function. CMS is enforcing noncompliance.

Why functional limitation reporting?

CMS created FLR to collect information regarding beneficiaries’ functions and conditions, the services therapists provide, and the functional outcomes patients achieve. CMS will use all of this information to better understand the beneficiary population that uses therapy services and how their functional limitations change as a result of the therapy they complete. Furthermore, CMS will use the data they collect to reform future payment structures.

Does FLR apply to rehab therapists?
According to the APTA, “All practice settings that provide outpatient therapy services must perform FLR. Specifically, FLR applies to physical therapy, occupational therapy, and speech-language-pathology (SLP) services furnished in hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians, and nonphysician practitioners.”

How does FLR work?
Therapists will report functional limitations (current status and projected goal for initial examination and at minimum every tenth visit or progress note, and then discharge status and projected goal at discharge) using G-codes and corresponding severity modifiers for all eligible Medicare patients.

What are G-codes and severity modifiers?
G-codes are quality data codes therapists will use to describe their patients’ functional limitation—that is, the primary reason they’re seeking therapeutic services. Upon identifying the primary functional limitation, the therapist will select the corresponding G-code and then assign a severity modifier, which indicates the extent of the severity of the functional limitation. Therapists select an appropriate severity modifier based on the score of an outcome measurement tool as well as their skilled clinical knowledge. Lastly, therapists must also include a therapy modifier (GO, GP, and GN) to indicate that they’re providing therapy services under an OT, PT, or SLP plan of care, respectively.

For a full list of the FLR G-codes and a severity modifier chart, check out this blog post.

What are the benefits of FLR?

With FLR, rehab therapists finally have an outlet to prove that what they do clinically is relevant and deserves payment. It’s an opportunity for rehab therapy professionals to demonstrate the value of their profession. FLR also allows rehab therapists to incorporate clinical judgement to truly assess the severity of a patient’s functional limitation without relying  on patients’ faulty self-assessments, and that leads to better, more effective treatment.

The Nitty Gritty 

Is FLR a requirement for patients with Medicare as a secondary insurance? What about for patients with a Medicare replacement or Medicare Advantage plan?

Currently, FLR is only a requirement for patients who have Medicare proper as their primary or secondary insurance. Patients with Medicare replacement or Medicare Advantage plans are technically commercially insured and thus, are not FLR-eligible.

When should my clinic be ready for FLR?

WebPT recommends that you begin completing functional limitation reporting for your current eligible patients on their next qualifying visit (IE, RE, PN, DS). After July 1, 2013, CMS will not reimburse you for services you provide to a patient if you don’t have that patient’s FLR data on record. Thus, for any current patients that you do not complete FLR on prior to July 1, 2013, you will need to complete a progress note on their first visit following this date, regardless of when you completed their previous progress note, to receive reimbursement. (If you’re a WebPT Member, we’ll prompt you to begin reporting FLR today, so you’re fully prepared—and compliant—when it’s mandatory in July.) For new patients beginning treatment after July 1, 2013, you will begin functional limitation reporting on their initial examination.

Is this G-coding requirement applicable to home health PT/OT/ST?

According to the APTA, “All practice settings that provide outpatient therapy services must perform FLR. Specifically, FLR applies to physical therapy, occupational therapy, and speech-language-pathology (SLP) services furnished in hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians, and non-physician practitioners.”

Based on this quote, home health agencies must perform functional limitation reporting when the beneficiary is not under a home health plan of care.

Once a patient with multiple functional limitations reaches goal status on his or her primary functional limitation, how do I switch the patient to a new primary functional limitation? Can I do two progress notes in two successive visits?

If a new primary functional limitation exists once the patient reaches the goal of their initial primary functional limitation, you’ll take the following steps:

  • Discharge initial primary limitation.
    • Within the Subjective Section, determine and select a new functional limitation category.
    • Within the Objective Section, select a new appropriate functional assessment tool(s) or objective measure(s).
    • Then, based on the functional assessment tool(s), determine the severity of this new limitation and select the corresponding modifier.
  • Determine the new projected long-term goal based on the current functional limitation status and other patient information.
  • Find the appropriate G-code and modifier on your billing sheet. If you have integrated billing, these will pass through the integration to the appropriate billing software:
    • Initial functional limitation
      • discharge status with severity modifier
      • projected goal status with severity modifier
    • New functional limitation
      • current status with severity modifier
      • projected goal status with severity modifier

My clinic does not use billing software that is compatible with WebPT, so we do the manual data-entry method. How should the actual claim appear to Medicare? Can you give me an example of what a HCFA 1500 will look like for billing a visit to Medicare?

For easy data entry, all of the G-codes from functional limitation reporting appear in WebPT's billing report. In submitting claims, you’ll report FLR G-codes as a separate line item. Basically, you’ll have your regular CPT codes indicating what you’ve done for the treatment, and then you’ll list your G-codes as part your non-payable codes ($0.00 Private or $0.01 Institutional). Functional limitation data is comprised of three pieces of info: G-Code, Severity Modifier, and Therapy Modifier. For multiple page claims, complete total for item 27 on the last CMS-1500 claim form.

To see an example or hear Heidi explain this all further, please watch our Functional Limitation Reporting Webinar here:

If a patient does not continue therapy, and I did not know in advance that his or her most recent visit would be the last, how should I complete the discharge note?

You would complete a quick discharge. This note would not contain the discharge G-code and severity modifier because you’re not generating a claim for the visit. You would then explain in the notes about the patient not continuing therapy. CMS would not assess a penalty for missing information because there would be no claim for the visit.

How does one use an outcome measurement tool to find a percentage score and select the proper severity modifier? Many functional tests don't directly produce a percentage that corresponds to severity modifiers.

Clinical judgment must always play a role in functional limitation reporting. Upon selecting a patient’s primary functional limitation, a therapist must select a corresponding modifier based on the combination of an outcome measurement tool and clinical judgment. In short, it’s not about cross-walking a score for an objective measure to a category of severity. It’s about demonstrating clinical expertise.

What should I do if a patient achieves the original goal of his or her primary functional limitation, but there is still potential for additional improvement? Should I set a new goal or would it be necessary to “discharge” the first goal?

If, during a certain episode of care, you determine that a patient’s projected goal is either too high or too low, you would simply change the goal status on the next progress note and document why in the note.

Can my PTA or OTA complete FLR?

While PTAs and OTAs can assist the PT or OT, respectively, neither PTAs nor OTAs may complete functional limitation reporting. Medicare addresses the involvement of the PTA and OTA in the evaluation and re-evaluation of patients in the Medicare benefit policy manual:

“A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.”

There is additional information about PTA patient care and supervision on the APTA website:

Should I bill 97002 every time I do a progress note with functional limitation reporting?

No, a typical progress note, even one with functional limitation reporting, does not require a 97002 code. In fact, you should only ever bill for a re-exam if one of the following situations apply:

  • The professional assessment indicates a significant improvement or decline or change in the patient’s condition or functional status that was not anticipated in the plan of care for that interval
  • New clinical findings
  • Failure of the patient to respond to the treatment outlined in the current plan of care  

Must I complete an outcome measurement tool at discharge?

Yes, an outcome measurement tool paired with your clinical judgment is what you will use to determine that your patient has, in fact, met their primary functional limitation goal and thus, is ready for discharge. You should be performing an outcome measurement tool consistently at every evaluation to objectively test your patient’s progress towards their goal.

What falls into the “Other” category of functional limitations?

You may use the “Other” category to indicate that you are treating the patient for a limitation that falls outside of the categories available. For example, urinary incontinence and pelvic health fall within the “Other” category. If you are treating a patient for pain or lymphedema, consider how this is affecting your patient’s daily life—there may be a clear functional limitation, like mobility or self-care. If not, you may use the “Other” category for these as well.

The Simplification (Why WebPT Makes FLR Easier)

What changes do I need to make to my workflow to accommodate FLR?

First, you must complete functional limitation reporting for all Medicare patients you treat. You’ll denote current status and projected goal status for the initial examination and at minimum every tenth visit or progress note. Then, you’ll note discharge status and projected goal at discharge. All of this you’ll do using G-codes and corresponding severity modifiers.

Your documentation method will greatly influence how you will incorporate FLR into your workflow. Paper charting will prove the most cumbersome with FLR as you’ll need to constantly reference a G-code list and severity modifier chart until you have it all memorized. You’ll also have to revise your paper charts to accommodate this reporting.

If you document digitally, then it’s crucial you have a conversation with your EMR vendor to ensure they’re entirely prepared for FLR. Depending on how they have FLR set up within the system, you may need to adjust your workflow. WebPT, on the other hand, has fully integrated FLR into the SOAP Note, meaning therapists’ documentation style and flow can remain the same.

How do I know if my clinic is compliant with FLR?

This also depends on how you document. If you chart on paper, then unfortunately, the only way you’ll know if you’re completing FLR accurately is if CMS reimburses you for your services—or doesn’t.

If you document digitally, then your EMR should have alerts in place to ensure you’re entirely compliant with your reporting. For example, WebPT won’t let you advance in your SOAP Note or create new notes (i.e., initial exam, progress note, or discharge summary) without completing FLR requirements. Furthermore, with WebPT, it’s not possible to finalize a note without completing FLR requirements.

What’s the easiest or fastest way to become compliant with FLR?

The easiest and fastest way to become entirely compliant with FLR is to let WebPT do all the heavy lifting for you. We’ve already integrated FLR into our application to ensure that all of our Members are compliant by the time the mandated regulations go into effect.

How does WebPT handle FLR better or differently than competitors?

Our solution is unique in its integration within the existing documentation framework. While most other EMR systems make functional limitation reporting more of an accessory that appears at the end of a patient note, WebPT has built it right into the documentation. This approach creates a stronger connection between functional limitation reporting and actual patient progress, thus maximizing the opportunity therapists now have to prove their effectiveness in treating and healing patients.

Don’t have WebPT yet? We can have your clinic up and running in one day. Schedule your free demo today.

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