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Outpatient Therapy Services Must Assign G-Codes or Face Medicare Denials

As of July 1, 2013, Change Request 8005 requires outpatient therapy service providers to report new functional G-codes and modifiers on claims for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services or face Medicare payment denials. The G-codes will be used to identify the primary issue being addressed by the therapy, and the modifiers will identify the severity or complexity of the patient, as well as their change over time. The policy includes a list of 42 new non-payable G-codes, 14 sets of three codes each, and seven new severity/complexity modifiers on therapy claims.

This change became effective for therapy services with dates of service on and after January 1, 2013. However, the first six months are a testing period for providers to acclimate to the new coding requirements. During this pre-July 1 testing period, claims without G-codes and modifiers will be processed. Claims for therapy services with dates of service on or after July 1, 2013 that do not have the appropriate G-codes and modifiers will be returned or rejected. In addition, providers may not bill the patient for the rejected services.

After July 1, 2013, the correct G-codes and modifiers must be included on claim forms at the outset of the therapy episode, every 10 treatment days or every 30 calendar days (whichever is less), and at discharge. According to CMS transmittal 1196, contractors are required to alert providers, with the exception of institutional providers, to include the new G-codes with modifiers on future therapy claims through a Remittance Advice Message as of April 1, 2013.

Specifically, the new policy applies to PT, OT, and SLP services furnished in hospitals, critical access hospitals, rehabilitation agencies, comprehensive outpatient rehabilitation facilities, skilled nursing facilities, home health agencies (when the beneficiary is not under a home health plan of care), and private offices of therapists and physicians. The policy also applies to non-physician practitioners, including nurse practitioners, physician assistants, and certified nurse specialists.

In response to these changes, therapy providers must ensure that their billing staff has familiarized themselves with these new requirements for correctly billing Medicare Part B claims. If you need assistance in preparing for these changes, or need assistance preparing for and/or defending against Medicare audits, please contact an experienced health care attorney at Wachler & Associates at 248-544-0888.