On a qualified patient’s initial evaluation, we must select the category that best represents the patient’s functional status (e.g., Mobility: Walking and Moving Around; Changing and Maintaining Body Position; or Carrying, Moving & Handling Objects). This determines which G-code we report.
Full Answer
What is a Medicare Progress Report and why is it important?
· Occupational therapy practitioners have a key role in assessing functional cognition and ensuring that Medicare beneficiaries in post-acute care settings receive the right care in the right setting. Occupational therapists use everyday task performance to identify cognitive impairment and inform the plan of care.
What is the proper format for a progress note for Medicare?
· occupational therapy evaluation, moderate complexity, requiring these components: an occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; an assessment(s) that …
Where can I find the progress timeline for a functional measures?
therapist. The checklist supports high quality occupational therapy evaluations that lead to occupation-based, client-centered interventions and quality performance measures. A comprehensive occupational therapy evaluation is based on a theoretical model and follows the Occupational Therapy Practice Framework (AJOT, 2020). A top-down approach ...
When does a therapist complete a progress note for a patient?
Spotlight Discontinuation of Functional Reporting for PT, OT, and SLP Services The Functional Reporting requirements of reporting the functional limitation nonpayable HCPCS G-codes and severity modifiers on claims for therapy services and the associated documentation requirements in medical records have been discontinued, effective for dates of service on and after January …
What are the three components of an occupational therapy evaluation that are used to determine the complexity of the evaluation?
Identifying and reporting the complexity level of an evalu- ation focuses on the first three of these components: profile and history, assessment, and clinical decision making. These three components must be documented in the medical record to support the choice of a code level.
What is a OT evaluation?
The purpose of an evaluation visit is to assess areas of function so that the occupational therapist can develop a treatment plan to meet the patient's specific needs. The areas assessed during an OT evaluation depend on the patient's age, diagnosis, and rehabilitation needs.
Does Medicare require functional limitation reporting?
Functional limitation reporting (FLR) for Medicare Part B patients is no longer required as of January 1, 2019. Physical, occupational, and speech therapists may choose to participate in FLR for Medicare during 2019, but have no obligation to do so.
When should a re-evaluation be performed?
A formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
Why is evaluation important in occupational therapy?
Evaluation is a core component of the occupational therapy process. To draw meaningful conclusions about the effectiveness of occupational therapy practice, it is essential that therapists consider not only what outcomes are achieved, but also reflect on how interventions are delivered.
Why are OT assessments important?
An occupational therapy assessment is an important stage of the occupational therapy process. These assessments are tools used by therapists to gather important information about your child. The purpose of this assessment is to: Identify concerns and difficulties your child is facing.
What are examples of functional limitations?
Functional limitations include difficulty with grasping and fine manipulation of objects due to pain, locking, or both. Fine motor problems may include difficulty with inserting a key into a lock, typing, or buttoning a shirt.
What are functional reports?
Reporting by function is an internationally recognised means of reporting government activities for comparison purposes. It provides a useful means of understanding government outlays as it allows for the reporting of expenses according to their purpose.
What is the difference between administrative and functional reporting?
Subordinate positions never report administratively to more than one higher level supervisor. A functional reporting relationship establishes a connection between positions or organizational units at different management levels based on the specialized nature of the function for which a mutual responsibility is shared.
How often do you need a progress note for Medicare?
every 10 treatment daysProgress Reports Medicare requires a Progress Report be completed at least every 10 treatment days. The next reporting period begins on the next treatment day after the Progress Report was performed.
What is the CPT code for occupational therapy evaluation?
CPT® 97166, Under Occupational Therapy Evaluations The Current Procedural Terminology (CPT®) code 97166 as maintained by American Medical Association, is a medical procedural code under the range - Occupational Therapy Evaluations.
What is procedure code 97162?
97162 - Physical therapy evaluation: moderate complexity, requiring these components: • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of. care; • An examination of body systems using standardized tests and measures in addressing a total of 3 or.
What is the OT process?
The process of OT includes evaluation, intervention, and tar- geting of outcomes that occur in the environments and contexts of the client to assist them in achieving health, well-being, and participation in life through engagement in occupation (AOTA, 2014).
What does an OT for kids do?
Occupational therapists help children do everyday things like eating, dressing, going to school and going out in the community. An occupational therapist might help if your child has physical or psychological challenges, developmental delay or intellectual disability.
What is an OT screening for kids?
The Preschool and School Age OT Screening Checklists are practical screening tools for teachers, parents and therapists. These checklists highlight common areas that are important for kids to be able to participate and succeed in during every day routines at home, school or in the community.
What is POC modification?
POC modification is necessary when a patient’s status changes. The therapist must then obtain physician signature for the updated POC. So, what constitutes a status change? Typically, there is a disruption to care (e.g., the patient is hospitalized for a medical issue unrelated to the current condition for which he or she is being treated) or a new issue or event arises that you feel requires prompt attention and treatment (e.g., the patient is receiving treatment for a lumbar diagnosis and is now complaining of shoulder pain, or the patient was receiving treatment for knee pain when he or she sustained a fall, and he or she now presents with an ankle fracture that does not require surgical intervention).
What happens if a POC is delayed?
What happens if certification is delayed? Under the current guidelines, it is the therapist’s responsibility to submit the POC to the prescribing physician in a timely manner. The therapist should also document all attempts to contact the physician to request POC signature in case there is a significant delay in obtaining it. If you ever end up submitting an appeal following a technical denial (i.e., a denial that occurs after certification is not obtained within the appropriate time period), it is crucial that you have this documentation. Some facilities may have a system in place in which a certain individual monitors POCs and follows up on those that have not been certified. This is a more common practice in hospital settings, where there is usually a specific person or people appointed to implement and oversee compliance measures. Regardless, it is in every practice’s best interest to monitor the certification process in order to ensure that this requirement is met.
What is Medicare Part B?
Medicare Part B is the component of Medicare that allows for the delivery of outpatient services. The general guidelines associated with billing for these services (including physical therapy, occupational therapy, and speech-language pathology) include establishing the plan of care (POC), certifying the plan of care by obtaining the signature of the referring physician or qualified NPP (non-physician practitioner), submitting progress notes at specified intervals, recertifying the POC after the expiration date if services are to be continued, including measurable short- and long-term functional goals, and completing functional limitation reporting (a.k.a. G-code reporting).
How long does a POC last?
You will establish your initial certification period after you conduct your evaluation. At this time, you’ll decide on the duration (number of weeks or treatment sessions) and frequency (number of times per week that treatment should occur). While the maximum certification period for any interval is 90 days, the certification period may expire prior to this time frame if the therapist selects a different duration. For example, if you evaluate a patient and decide that an eight-week period of treatment is adequate, the POC will expire in 60 days rather than 90. This means you must complete a recertification note when the POC expires (if there’s a change in the patient’s status warranting the continuation of care).
What is reasonable and necessary?
The term “reasonable and necessary” often invites some confusion when it comes to documentation, as there are indeed some gray areas here. CMS defines this term as follows: “the service is considered, under accepted standards of medical practice, to be a specific and effective treatment for the patient’s condition.” While this is a fairly clear definition, the manner in which we apply it as therapists can vary widely based on our training and experience. For instance, one therapist may initiate treatment for a patient who presents with edema around the knee and decreased knee flexion by implementing ultrasound and PROM, while another therapist may perform edema massage and instruct the patient in an AROM program with a TENS unit in place to manage pain during exercise. Both approaches are valid, and both can be viewed as specific and effective. Is one approach superior to the other? While some cases (e.g., a patient s/p rotator cuff repair) may require a therapist to follow a specific protocol as outlined by a physician, most situations allow us the freedom to select the most beneficial techniques and treatments for our patients. As a result, outcomes may vary greatly from one practitioner to another and could be affected by a number of other variables (e.g., patient attendance, motivation, and presence of co-morbidities). According to CMS, the other factor at play with the “reasonable and necessary” standard is that the patient must require a type of service that only a therapist—or qualified professional working under the supervision of a therapist—can safely and effectively perform.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Therapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
When did functional reporting begin?
Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report nonpayable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
How many G codes are there?
There are 42 functional G-codes that are comprised of 14 functional code sets with three types of codes in each set. Six of the G-code sets are generally ...
What is a TEP?
The TEP was composed of a diverse group of stakeholders with HH, PAC and functional assessment expertise. A summary (PDF) of the TEP meeting, including the objectives and proposed measure concepts can be found on the IMPACT Act of 2014 Archived Information website.
What is the impact act?
113–185) directed the Secretary to specify quality measures on which PAC providers are required under the applicable reporting provisions to submit standardized patient/resident assessment data and other necessary data specified by the Secretary with respect to five (5) quality domains, one of which is functional status, cognitive function, and changes in function and cognitive function.
What is the ASPE project?
A joint effort led by Assistant Secretary for Planning and Evaluation (ASPE) with support from CMS, focused on measure development in the area of functional outcomes. The activities conducted in this joint effort included an environmental scan, the analyses of the CARE Item Set and other functional status data, and integration of extensive input received from a Technical Expert Panel convened by RTI International. These activities have led to an initial development of two motor functional status quality metrics: self-care and mobility, using the standardized functional status data elements from the CARE Item Set.
What is the therapy revenue code for a nonpayable functional G code?
A19) Yes, on the line of service for each nonpayable functional G-code, use the appropriate therapy revenue code – 420, 430, or 440 – to correspond to the therapy modifier – GP, GO, or GN, respectively.
Can a therapy assistant report modifiers?
A9) Yes, the therapy assistant who furnished the services can report the G- codes and modifiers to begin reporting for a second functional limitation when a therapist previously determined the functional information.
Does mandatory assignment apply to therapy?
The mandatory assignment provision does not apply to therapy services furnished by a physician/NPP or "incident to" a physician's/NPP’s service. However, when these services are not furnished on an assignment-related basis; the limiting charge applies.
How long is a delayed NPP certification good for?
Certifications are acceptable without justification for 30 days after they are due. Delayed certification should include one or more certifications or recertification's on a single signed and dated document.”
