CPT Code for Physical Therapy Evaluation and the Functional Limitation G Codes for Medicare Claims

CPT Code for Physical Therapy Evaluation is CPT Code 97001

Remember your CPT Code for Physical Therapy Evaluation 97001 must only be billed once per condition, per episode and per problem with 1 unit. It is a Faced-to-Faced Encounter, non-time based and no matter how long you spent time with the patient, you will still bill one unit for CPT Code for Physical Therapy Evaluation.

I wrote this article about the PT Evaluation code plus the Functional Limitation G Codes that you must submit with your claims for Medicare.

This article is based on Medicare Processing Manual Revised 2859 Issued 01-17-2014, Effective 01-01-2014 and with an Implementation Date of 01-31-2014. As of this writing, the guideline is still the same.

Functional Reporting ( see reference – Rev. 2859, Issued: 01-17-14, Effective: 01-01-14, Implementation: 01-31-14) Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Act to require a claims-based data collection system for outpatient therapy services, including Physical Therapy (PT), Occupational Therapy (OT) and Speech-Language Pathology (SLP) Therapy services.

I think that this is going to be a big help in research and data gathering. Because what it does is that, the system will collect and gather data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures.

These Functional G Codes are being reported using 42 NON-Payable functional G-codes and seven severity-complexity modifiers on claims for PT, OT, and SLP services. Meaning, they are only used for data gathering. And that is functional reporting on one functional limitation at a time is required periodically throughout an entire PT, OT, or SLP therapy episode of care.

The nonpayable G-codes and severity modifiers are used for information gathering purposes about the patient or beneficiary’s functional status at the outset of the therapy service episode of care, including the status of projected goals, at specified points during treatment, and at the time of discharge. I honestly like these functional limitations reporting!

These G-codes, along with the associated modifiers, are required at specified intervals on all claims for outpatient therapy services, not just those over the cap.

Therapy Billing Services covered with this new rule

Date of Service on or after July 1, 2013, that does not have the required functional G-code and modifier information will be returned or rejected. Date of Service prior are in testing phase. So as I am writing this post, rest assured that anything after July 1, 2013 must have your G-codes appended. I make sure my CPT Code for Physical Therapy Evaluation must be reported with G-codes on that particular date of service. Check your Therapy Billing notes.

Therapy Billing Services Affected with these new requirements: Medicare Claims Processing Manual Chapter 5 – Part B Outpatient Rehabilitation and CORF/OPT Services (Rev. 3367, 10-07-15)

“These requirements apply to all claims for services furnished under the Medicare Part B outpatient therapy benefit and the PT, OT, and SLP services furnished under the CORF benefit. They also apply to the therapy services furnished personally by and incident to the service of a physician or a nonphysician practitioner (NPP), including a nurse practitioner (NP), a certified nurse specialist (CNS), or a physician assistant (PA), as applicable.”

Who are affected?
All Therapy Billing Services rendered under the Medicare Part B outpatient therapy benefit Physical Therapy, Occupational Therapy and Speech Language Pathology Therapy Billing Services from CORF benefit Therapy rendered personally by, or incident to the service of a non-physician or physician, nurse practitioner, physician assistants and certified nurse specialists.

Here are your codes. So before you apply your CPT Code for Physical Therapy Evaluation, make sure you check your therapist notes and look for these G Codes

How does G-Codes look like?

42 Fnctional G-codes
14 Sets of three codes each
Six of the G-code sets are generally for PT and OT functional limitations
Eight sets of G-codes are for SLP functional limitations

See table below: You can get the entire manual here:  https://www.mspinkymaniri.com/wp-content/uploads/2016/03/Chapter-5-Medicare-Claims-Processing-Manual-Part-B-Outpatient-Rehabilitation-and-CORF-OPT-Services-Rev-3367-10-07-2015.pdf



Therapy_Functional_Limitation_G_Codes_3 Therapy_Functional_Limitation_G_Codes_2

How About the KX Modifier? How do you append the KX Modifier if applicable for therapy billing?

When the Beneficiary has reached Cap and meets the necessity for KX Modifier, you don’t need to append the KX Modifier with the Functional Limitation G Code Modifier.


FOR REFERENCE CLICK HERE PLEASE: https://www.mspinkymaniri.com/wp-content/uploads/2016/03/Chapter-5-Medicare-Claims-Processing-Manual-Part-B-Outpatient-Rehabilitation-and-CORF-OPT-Services-Rev-3367-10-07-2015.pdf

You can read more related Medicare Claims Processing Manual here: https://www.mspinkymaniri.com/downloads122014/

Learn more about Therapy Billing



Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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