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Claims Based Data Collection G-Code Requirement for Part B Billing

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The Middle Class Job Creation and Tax Relief Creation Act (MCTRJCA) of 2012 established criteria to manage expenditures for Outpatient or Part B services for all outpatient/Part B therapy services, regardless of the setting.

This legislation outlines the following:

  • Established the Manual Medical Review/Advanced Approval Process and a $3,700 cap
  • Also directed congress to study OP outcomes/implement a data based outcomes tool
  • Exceptions to the therapy caps remain in effect (KX modifier)
  • Hospital OP and Critical Access Hospitals (CAHs) claims for therapy services are included in the $1900 and $3700 cap
  • Editing remains in effect to suspend claims for therapy services that exceed the $3700 cap
  • Directed Congress to form a task force to study the efficacy of Part B services
  • The Claims Based Data Collection has been designed to provide collection of data on patient function during the course of therapy services to better understand patient condition and outcomes
  • G codes are 42 new non-payable functional G-codes and 7 new modifiers that will be submitted on all claims for Outpatient/Part B PT, OT and SLP services
  • G code and modifier is selected by the registered therapist and will be integrated in Casamba
  • G codes and modifiers will be added at the time of the initial evaluation, every 10th visit (or before) and at the time of the Discharge to give a measurement of baseline, progress and status as the time of discharge
  • Compliance with submission of the G codes and modifiers is required by the June 30th, 2013 deadline

All therapists should consider the following when selecting the G code and associated modifiers:

  • Does the G code BEST represent the main focus area of therapy and the one that you would expect the most impact?
  • Did you document on the G code status as well as the goal?
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