G Code changes for 2011
The new year approaches with new changes
G Code Changes for 2011 and how it affects your agency
The New and Revised G-Codes and More Specific Information Sought by CMS Effective 1/1/11 http://www.coms.gov/transmittals/downloads/R824OTN.pdf CMS is seeking more specific information regarding who is visiting the patient, ie; a PT or a PTA or an OT or COTA. In addition, they are seeking to categorize skilled nursing visits into four categories: direct skilled nursing care, management and evaluation, observation/assessment, and training/education. At the end of this article you will see a link for some reference guides and two videos where we discuss the G Code changes for 2011. What Could This Mean to a Home Health Agency? It means that now more than ever documentation MUST support the visit TYPE and that visit TYPE had best support the POC. If a patient’s visit required education and training and this is the fifth education/training visit, it begs the question: “when is the clinician going to modify the teaching; content or method?” Visit notes will need to clearly justify the visit and show the value as it relates to the orders/goals of the POC. Now, for an auditor, it will be easier to see two or three recertifications of a chronic disease and pull out visits by type and ask specific questions. It will make it easier to deny visits. Remember, an episode doesn’t need to be fully denied, just having 5 of 14 visits denied could realize a $1000 episodic loss, depending on the patient HIPPS/HHRG. As to therapy, now agencies can no longer have a qualified PT open a case and in effect turn it over to an assistant. Most agencies do not do this but, there have been cases. In addition, in specific cases, would having a qualified therapist vs an assistant have made a difference in patient outcome? This will be reviewed. CMS believes it is paying for qualified therapy and expects to see the results of having the higher educated therapist actively involved with the patient’s care. (This is one reason for the mandated qualified therapist to functionally assess the patient on the 13th and 19th therapy visit. This is set to go into effect 4/1/2011). The clinician is to report the G-code that reflects the service provided for most of the visit.
- Per the transmittal, “In order for CMS to collect more specific information regarding the sort of services provided to home health patients, we are revising the current descriptions for existing G Codes for physical therapists (G0-151), occupational therapists (G0-152), and speech language pathologists (G0-153), to include the descriptions that they are intended for the reporting of services provided by a qualified physical or occupational therapist or speech/language pathologist.”
“In addition, we are adding two new G-codes (G0-157 and G0-158) for the reporting of physical therapy and occupational therapy services provided by qualified therapy assistants”
- G0-151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
- G0-152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
- G0-153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
- G0-157 Services performed by a qualified physical therapy assistant in the home health or hospice setting , each 15 minutes.
- G0-158 Services performed by a qualified occupational therapy assistant in the home health or hospice setting, each 15 minutes.
“We are also adding and requiring three new G-codes for the reporting of the establishment or delivery of therapy maintenance programs by qualified therapists. The following are descriptions for those new G-codes, for the reporting of the establishment or delivery of therapy maintenance programs by therapists:”
- G0-159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes.
- G0-160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes.
- G0-161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes.
So, what does the Medicare Benefit Policy Manual Chapter 7 have as outlined Skilled Therapy Services?
- Section 40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy identifies that skilled therapy services must be reasonable and necessary to the treatment of the patient’s illness or injury or to the restoration or maintenance of function affected by the patient’s illness or injury. “It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient’s overall condition, skilled management of the services provided is needed although many or all of the therapeutic services needed to treat the illness or injury do not require the skills of a therapist.” Chap 7, 40.2,1
Section 40.2.2 Application of the Principles to Physical Therapy Services:
- A. Defines Assessment,
- B. Identifies Therapeutic Exercises and supervision,
- C. Gait Training defined,
- D. Range of Motion as treatment of an active disease process
- E. Maintenance therapy to maintain function,
- F. Ultrasound, Shortwave, and Microwave Diathermy Treatments
- G. Hot Packs, Infra-Red Treatments, Paraffin Baths, and Whirlpool Baths
- H. Wound Care Provided Within Scope of State Practice Acts
- 40.2.3 Application of the General Principles to Speech-Language Pathology Services. Specific requirements for reevaluation are well defined to include: a change in functional speech, clearing of confusion, remission of another condition, where the services are expected to materially improve a condition, to establish a hierarchy of speech-voice-language communication goals, train the patient or family member, assist with aphasia, and assist with voice disorders.
- 40.2.4 Application of the General Principles to Occupational Therapy.
- 40.2.4.1 Assessment and to reassess.
- 40.2.4.2 Planning, Implementing, and Supervision of Therapeutic Programs to include: Teaching task oriented therapeutic activities designed to restore physical function, plan, implement, and supervise therapeutic tasks and activities designed to restore sensory-integrative function, plan and implement “Active Treatment“ programs. In addition, teaching compensatory techniques to improve the level of independence in ADLs and designing, fabricating, and fitting orthotic self-help devices, as well as prevocational assessment and training.
- 40.2.4.3 Illustration of Covered Services
Example 1: “A physician orders OT for a patient who is recovering from a fractured hip and who needs to be taught compensatory and safety techniques with regard to lower extremity dressing, hygiene, toileting, and bathing. The OT will establish goals for the patient’s rehabilitation (to be approved by the physician), and will undertake teaching techniques necessary for the patient to reach the goals. OT services would be covered at a duration and intensity appropriate to the severity of the impairment and the patient’s response to treatment.” What about skilled nursing? CMS is requiring classification of each home health visit into a specific category. The transmittal states: “Lastly, we are revising the current definition for the existing skilled nursing services (G0-154), and requiring home health agencies (HHAs) to use G0154 only for the reporting of direct skilled nursing care to the patient by a licensed nurse (licensed practical nurse or registered nurse).” Additionally, we are adding and requiring three new G-codes: One for the reporting of the skilled services of a licensed nurse in the management and evaluation of the care plan; another for the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse can determine the patient’s status until the treatment regime is essentially stabilized, and another for the reporting of the training and education of a patient, a patient’s family, or caregiver:
- G0-154 Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. Includes Injections, wound care, infusion, catheter changes.
- G0-162 Skilled services by a licensed nurse (RN only) for the management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non skilled care achieves its purpose in the home health or hospice setting).
- G0-163 Skilled services of a licensed nurse (RN or LPN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).
- G0-164 Skilled services of a licensed nurse (LPN or RN) in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.”
CMS continues with the following statement:
- “We recognize that, in the course of a visit, a nurse or qualified therapist could likely provide more than one of the nursing or therapy services reflected in the new and revised codes. HHAs must not report more than one G-code for the nursing visit regardless of the variety of nursing services provided during the visit. Similarly, the HHA must not report more than one G-code for the therapy visit, regardless of the variety of therapy services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA must report the G-code which reflects the services for which the clinician spent most of his/her time.”
- G0-154 Direct skilled services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes. Includes Injections, wound care, infusion, catheter changes.
- For coverage criteria see MBPM Chapter 7:
- See section 40.1.2.4 Administration of Medications
- See section 40.1.2.5 Tube Feedings
- See section 40.1.2.6 Nasopharyngeal/Trach Aspiration
- See section 40.1.2.7 Catheters
- See section 40.1.2.8 Wound Care
- See section 40.1.2.9 Ostomy Care
- G0-162 Skilled services by a licensed nurse (RN only) for the management and evaluation of the plan of care, each 15 minutes (the patient’s underlying condition or complication requires an RN to ensure that essential non skilled care achieves its purpose in the home health or hospice setting).
- Management and Evaluation is a skilled nursing program introduced in 1989. The coverage criteria is found in CMS Publication 100-2, MBPM Chapter 7, 40.1.2.2 for several concepts of M&E including:
- Underlying Conditions/Complications (Patient must be at risk for hospitalization or health problem exacerbation)
- Complexity of necessary unskilled services (Plan must be complex)
- Essential Nonskilled Care (Caring situation is unstable)
- Necessary Part of Medical Care
- Only an RN Can Ensure (An RN must be involved with care)
- Promote Patient’s Recovery and Medical Safety
- G0-163 Skilled services of a licensed nurse (RN or LPN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting).
See the Medicare Benefit Policy Manual Chapter 7 40.1.2.1 outlines “Observation and Assessment of the Patient’s Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient’s Status.” From the segmentation of the visit types, one can see that documentation becomes even more important. Documentation needs to be specific and congruent with the POC orders and goals based on the SOC OASIS integrated assessment. There needs to be adequate support for the visit type in relation to the expected and achieved outcomes. Summary Sheet
- G-154 SN (LPN and RN) Direct Care
- G-162 SN (RN Only) Management and Evaluation
- G-163 SN (LPN and RN) Observation and Assessment
- G-164 SN (LPN and RN) Training and Education
- G-151 Qualified PT Direct Care
- G-159 Qualified PT Therapy Maintenance Program
- G-157 PT Assistant
- G-152 Qualified Occupational Therapy Direct Care
- G-160 Qualified Occupational Therapy Maintenance Program
- G-158 Occupational Therapy Assistant
- G-153 Qualified S/LP Direct Care
- G-161 Qualified S/LP Maintenance Program
These G-codes remain the same:
- G-155 Clinical Social Worker
- G-156 Home Health Aide
If you would like to purchase for your convienence a laminated two sided Nursing and Therapy G Code Reference Guide. Visit the links below.
G Code Video Link
CY 2011 UpdatesFAQ
Over the past few weeks, many of our clients have called with questions regarding the CY2011 Final Rule. We have collected several of the most frequently asked questions for you to review. Answer sources: November 17, 2010 Federal Register Final Rule, CMS: www.cms.gov/center/hha.asp, NAHC: teleconferences and written medium, CMS12/20 Bulletin, and MLN Matters Articles at the following site: www.cms.gov/MLNMattersArticles/downloads/SE1038.pdf. Question: “Does CY2011 Final Rule cover all Medicare and Medicaid beneficiaries?” Answer: The Rule is effective for fee-for-service Medicare patients admitted/SOC on or after January 1, 2011. (SOC only). Question: “If an agency provides care and the patient keeps promising to see a physician but does not can the patient be held liable for payment to the home health agency?” Answer: No, states CMS. HHABNs are not appropriate when non-coverage is due to failure to complete the face-to-face encounter. Agencies must give the patient advance notice of their responsibility to have the physician face-to-face encounter. Home health agencies may NOT hold the Medicare beneficiary liable for payment due to non-compliance with the face-to-face encounter. Question:”Can the physician sign the POC before completing the face-to-face encounter.” Answer: The POC may be signed prior to a face-to-face encounter as may occur if the patient sees the physician within 30 days of admission to care by a home health agency. However, both the POC and the face-to-face certification statement signatures MUST be present prior to submission of the final claim. Question: “What if the physician does not complete all required items on the face-to-face encounter form?” Answer: If the face-to-face encounter statements do not meet the requirements of CMS, as addressed in the CY 2011 Final Rule, agencies run the risk of having their claims denied. The agency must educate the physicians to the requirements. Question: “Since the face-to-face encounter occurs at the SOC for home health, does it only occur at the recertification for a second, 90 day benefit period for Hospice?” Answer: The face-to-face encounter requirement will track the benefit period status, no matter the number of days of hospice care delivered. For Hospice, the face-to-face encounter occurs at the start of the third benefit period, the 180th day recertification (the benefit period following the certification for the second 90 day benefit period). For Hospice the face-to-face encounter must occur atevery subsequent recertification. Question: “As to the new G-Codes, do therapy G-Codes go into effect January 1, 2011 or April 1, 2011?” Answer: All G-Codes, per CMS, are effective January 1, 2011. (However, many advocacy organizations are requesting a delayed implementation date). A Transmittal from CMS is due out soon. Question: “Which G-Code should be used for skilled nursing wound care, infusion, and catheter changes?” Answer: G-Code “154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the Home Health or Hospice setting, each 15 minutes.” Question: “How does an agency calculate the reassessment 13th and 19th visits? Should each discipline count their own visits individually or should we count all therapy visits? When does this go into effect?” Answer: Per CMS and NAHC “CMS goal is to ensure that the qualified therapist for EACH discipline providing services assess the patient before the TOTAL number of therapy visits reaches the 14th and 20th visit therapy threshold. Therefore, this is a combined therapy count. There has been speculation re “flexibility,” re reassessment visits and days, but, agencies should read the soon to be released transmittal regarding this before finalizing policy. CMS is to identify SPECIFICALLY how much flexibility will be given as to ranges of time for the qualified visit. Before the episode completion, the qualified therapist must document progress toward goals established to justify continued therapy. The therapy requirements, other than therapy G-Codes, go into effect April 1, 2011. Question: “Can a therapy assistant provide maintenance therapy visits?” Answer: No. The PPS Update Notice stated, “Maintenance therapy will continue to be covered in the home health setting when the unique condition of the patient requires the complex services, which can only be provided effectively and safely by a qualified therapist. Furthermore, the maintenance therapy G-Codes are defined as provided by the qualified therapist.” (p.124)