When Do I Have to Report G-Codes

March 27, 2017
Rick Gawenda

Functional Limitation Reporting (FLR) (i.e. G-codes) has been required for dates of service on and after July 1, 2013 for Medicare beneficiaries receiving outpatient therapy services being billed under their Part B Medicare benefits. I still receive many questions when G-codes have to be reported on the claim form. Many of the questions I receive concern if a therapist only bills an L code for an orthosis during the patients initial visit, do I need to report G-codes? Another question I receive is are G-codes required if on the first visit, I only bill CPT code 97542 for a wheelchair assessment or CPT code 97760 for an orthotic assessment and I do not bill a physical therapy or occupational therapy evaluation CPT code. Lastly, speech-language pathologists ask if they need to report G-codes when they are performing a modified barium study on a Medicare beneficiary who is under observation status or in the emergency department of the hospital?

In this article, I will answer these questions plus provide in what other situations and time frames G-codes are required to be reported on the claim form.

Functional reporting using the G-codes and corresponding severity modifiers are required on claims:

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  1. It is still correct that g-codes are only to be submitted with a procedure code? So if a patient stops coming and the d/c is not done on a treatment day, no code is reported?

    1. G-Codes can only be reported on a claim form the same date of service at least one CPT code is billed. G-codes can’t be billed on a claim form when no visit occurred that date of service.

  2. Is it still every 30 days or every 10th visit (whichever comes first)…..you bullet points above don’t mention the every 30 days rule.

      1. Does that mean the 30 day rule no longer exists? We recently had a patient who didn’t not self-discharge but had a gap in care due to having to cancel several visits in a row because of transportation issues; when she returned it had been over 30 days since we last saw her but only 5 visits from last functional reporting. Wouldn’t we need to do the functional reporting now due the 30 day rule?

  3. In general we are not getting paid for code 97760 when billed with an L code for Medicaid and Medicaid replacements. We are billing as follow: 97760,GP + Gcodes and modifiers + Lcode…The EOB is saying the procedure code 97760 is inconsistent with the modifier used or the required modifier is missing. Any suggestions with these payers??

  4. If the patient provides Medicare insurance information after care because they initially omitted coverage or the coverage is retroactive, What are documentation requirements? will therapist need to amend notes to include POC per medicare requirements? Can they choose g codes based on documentation and re-submit claim to medicare?

    1. The first date of service you bill to the Medicare program, all Medicare Part B rules and regulations would apply. This includes plans of care and functional limitation reporting.

  5. For patients in the acute care setting under observation status the plan of care needs a physician signature if treatment is provided- question is with the hospitalist schedule and rotations the physician that orders may not ever be in the facility to sign off on the plan- in this case where the hospitalist group model will the signature of another physician that is involved in the patient’s case be accepted?

  6. Are functional reporting codes required for Med A SNF OT PT evaluations, as well as for Part B Outpatient evaluations? My question arises from CMS MLN #9933 which states
    “Functional Reporting In addition to other Functional Reporting requirements, Medicare payment policy requires Functional
    Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and re-evaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting…

    1. FLR is required in all outpatient therapy settings that would include SNF Part B. In SNF Part A, you do not bill via CPT codes, rather, you are paid via RUG levels so FLR does not apply.

  7. When I call and speak with a provider rep at Humana or many of the other Med Adv plans when I ask about Gcodes most reply they cannot tell me if they are required or not and always go back to “we follow Medicare Guidelines”. Recently we have had several claims issues with Humana and Med Adv, but I know there had been claims issues recently. my billing office keeps asking if we now need to submit gcodes and again when I call really do not get a definitive answer – can you advise?

    1. Unfortunately, you have to check with each Medicare Advantage plan to see if they require Functional Limitation Reporting or not.

  8. If Medicare is the patient’s secondary insurance, do we still need to add functional codes?

  9. Discharge G-Code is required on a billable visit – clear.

    Discharge G-Code on a self-discharge – unclear.

    As a traveler in many OP settings, things seem really unclear facility to facility in terms of self-discharges. Some want the last note opened with addendum to include discharge g-codes, others want a g-code form to be filled out with the last date of service on it, some facilities including hospitals billing monthly just have the the billing department add the codes guesstimated from the last date of service if before month end. The reason stated is that if the codes aren’t submitted, they don’t get paid.

    What is correct? Anything to beware of?

    1. G-codes can only be reported on a claim form when a visit was provided that date of service and at least one CPT code was billed. If a patient stops coming to therapy unexpectedly, if the last claim where a visit was completed as not yet been submitted, you can go and do an addendum and add the G-codes with the severity modifiers to the claim form and the documentation. If the last claim has already been submitted, then the final G-codes will not be reported.

      1. Is there any risk in not adding the final G-code after the monthly claim has processed in the case of a self-discharge? In our hospital based outpatient department, we have been adding a G-code addendum on the date of the last billable therapy visit, frequently after the monthly claim has processed. We don’t want to risk retroactive payment denial, but if it’s not required we won’t spend time adding these late penny charges.

        1. In an unanticipated discharge where the last claim as already been submitted before you realize the patient is not returning, you would be unable to report the DC G-codes.