If you have started reporting functional limitations and have included the appropriate G codes and impairment modifiers on your claims, you will continue to report on patient status at the next reporting interval/progress report.
Full Answer
What happened to claims-based outcome reporting for Medicare?
For traditional Medicare, Claims-Based Outcomes Reporting (Functional Limitation Reporting) has ended for any services rendered on or after January 1, 2019. Any Medicare advantage or private plans who chose to adopt Functional Limitation Reporting may elect to continue the program so it is best to check directly with those payers.
What happened to claims-based outcomes reporting (functional limitation reporting)?
For traditional Medicare, Claims-Based Outcomes Reporting (Functional Limitation Reporting) has ended for any services rendered on or after January 1, 2019.
When is functional reporting required on therapy claims?
Functional Reporting is required on therapy claims for certain dates of service (DOS) as described below: At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service; At least once every 10 treatment days on the claim for services on the same DOS that the services related to the progress report are furnished;
What are the functional reporting requirements for nonpayable HCPCS G codes?
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 1, 2019.
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.
What is a functional modifier?
Functional modifiers provide additional information that impacts the amount of reimbursement either directly or through the use of Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) or our Correct Code Editor (CCE) edits.
What should a provider do when reporting more than four modifiers on the CMS 1500 claim?
NOTE: The Form CMS 1500 currently has space for providing four modifiers in block 24D, but, if the provider has more than four to report, he/she can do so by placing the -99 modifier (which indicates multiple modifiers) in block 24D and placing the additional modifiers in block 19.
What does KX modifier mean for Medicare?
The KX modifier is a Medicare-specific modifier that indicates a beneficiary has gone above their therapy threshold amount.
How do you know when to use a modifier?
Modifiers should be added to CPT codes when they are required to more accurately describe a procedure performed or service rendered.
How can the incorrect use of modifiers affect reimbursement of claims?
Incorrect usage of modifiers can result in revenue loss for a medical practice. If not used appropriately, faulty codes can lead to claims denials, reduced income for practices and compliance issues too. The coding modifiers are revised annually by payer organizations.
What is a final step in processing CMS-1500 claims?
Federal Privacy Act of 1974. A final step in processing a CMS-1500 claims is to: Double-check claims for errors and omissions.
How many diagnosis codes can be reported on the CMS-1500?
twelve diagnosesUp to twelve diagnoses can be reported in the header on the Form CMS-1500 paper claim and up to eight diagnoses can be reported in the header on the electronic claim. However, only one diagnosis can be linked to each line item, whether billing on paper or electronically.
How do you use the FS modifier?
Modifier FS will be used with claims for split (shared) visits performed in facility settings and split (or shared) critical care visits. Practices should not add the modifier to office or other outpatient visits (99202-99215).
What is the KD modifier?
KD modifier was created by Medicare. Any “Drug or biological substance infused through a DME (Durable Medical Equipment's),” Since the infusion of medications take place through an implantable pump (External Pump), then we should append modifier KD to the HCPCS code for that drug/biological substance.
In what scenario would use you use modifier KX?
Use the KX modifier to indicate that the clinician attests that services at and above the therapy caps are medically necessary and reasonable, and justification is documented in the patient's medical record.
How long can you use KX modifier?
Nope, there is no upper limit—as long as the services you are providing are medically necessary. However, there are additional steps you must take if you believe treatment beyond the manual medical review threshold of $3,700 is medically necessary.
When should PT/OT categorical G code be reported?
A18) A PT/OT categorical G-code set should be reported when it best describes the functional limitation being treated – even though the assessment tool used surveyed the beneficiary’s overall functional abilities, such as the ability to carry out his/her daily routine and other quality of life measures.
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.
What is the penalty for not reporting a claim to Medicare?
Under Section 111 of the Medicare, Medicaid and SCHIP Extension Act (MMSEA), failure to report by the required deadline can result in penalties of up to $1,000 per day, per unreported claim. The federal government also has the statutory ability to sue for double damages, in addition to the amount of the conditional payment.
What is the False Claims Act?
The federal government may use the False Claims Act (FCA) to file a claim against parties that attempt to commit Medicare fraud. The FCA defines a false claim as “any person who … knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the Government” and states that person “is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000 … plus three times the amount of damages which the Government sustains because of the act of that person”.
When does functional limitation reporting end?
For traditional Medicare, Claims-Based Outcomes Reporting (Functional Limitation Reporting) has ended for any services rendered on or after January 1, 2019. Any Medicare advantage or private plans who chose to adopt Functional Limitation Reporting may elect to continue the program so it is best to check directly with those payers.
When is it acceptable to document and report the same severity modifier for the current status and goal?
It is acceptable to document and report the same severity modifier for the current status and goal when the improvement is expected to be limited, or for those individuals receiving maintenance therapy. Documentation must justify the condition (s) reported on the claim.
When should you report therapy?
If a patient is seen by more than one discipline, each discipline should report the status and severity for their plan of care. Reporting should occur at the first visit (including evaluation), discharge, every date of service ...
Why are incorrect claims likely to have been repeated in later cost reports?
By then, the incorrect claims are likely to have been repeated in later cost reports because hospitals generally use cost reports from previous years to calculate succeeding cost reports. In these cases, it’s the hospital’s responsibility to report errors in other cost reports.
Who is the best source of information on Medicare fraud?
Insiders are the best source of information on Medicare fraud. Whistleblowers may file lawsuits even if they participated in the fraud. Congress figured insiders would be the best source of information about fraud, and employees are usually forced to participate in fraudulent schemes to keep their jobs.
What is the duty to disclose provision?
1320-7b (a)3] that makes concealing from the government or failing to report Medicare overpayments a felony. Under the “duty to disclose” provision, healthcare providers and others who conceal or fail ...
How much do whistleblowers get from Medicare?
To encourage people to report Medicare fraud, the law stipulates that whistleblowers will receive 15 percent to 25 percent of whatever money the government recovers as a result of their lawsuits, if the government joins the case and up to 30 percent ...
What is an overpayment in the False Claims Act?
An overpayment is considered “identified” when the person has or should have through the exercise of reasonable diligence, determined that an overpayment was received. Retaining an overpayment after it should have been reported can be a violation of the False Claims Act.
How long does it take to report an overpayment to the government?
The Affordable Care Act, enacted in 2010, included a provision that requires a person who receives a payment from Medicare or Medicaid to “report and return” the overpayment to the Government within 60 days of identifying it or, if applicable, within 60 days that the corresponding cost report is due, ...
What is the False Claims Act?
The False Claims Act allows private citizens as well as the government to sue individuals, companies or institutions that are defrauding the government and recover three times the government’s losses plus a penalty for each violation.