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Functional limitation reporting has been imposed on physical, occupational and speech therapists for Medicare Part B patients, effective July 1. With the stress and anxiety to learn and be ready to implement this new rule by that date behind them, along with working out the technical kinks to make sure the G codes and severity modifiers are transferring to the claims correctly, therapists now can sit back and reorganize their approach to the worst part of being a therapist: clinical documentation. 

Put simply, the G code classification and the “current status” modifier should be supported by the results and interpretations of documented functional tests, identified impairments and the therapist’s own clinical judgment, which should be centered on the functional limitation status. The “goal status” modifier should be supported by related short- and long-term goals that are unique to each patient, with further descriptions of impairment levels and granulated areas of functional deficit present. Even though many therapists are compelled to include the smallest of details, less than 10 percent of the extraneous information in therapy documentation is ever seen by another human eye. The therapist should concentrate on what auditors currently are looking for, which is everything related to the clinical judgment in choosing a particular G code classification and severity modifier.

How is it now possible for therapists to convey medical necessity in a more structured way? For the first time in hospital outpatient therapy history, Medicare is demanding the collection of standardized, functional data. This data is broken down into functional areas called “G codes.” They have simple “lay-person” titles (i.e., not set forth by professional associations), such as “mobility: walking/moving around,” “changing/maintaining body position,” “carry, moving/handling objects,” and “self-care.”   Speech and language pathologists have their own set of G codes, and some that they share with occupational therapists.

In reorganizing his or her approach to documentation with the advent of functional limitation reporting, the first questions the therapist needs to ask are these: What is the regulatory audience (i.e., CMS, TJC and payers) now looking for in my clinical reports? What information most likely will allow claims to be quickly processed and paid swiftly, with minimal risk of denials and lengthy appeals? What is the easiest and most effective way to convey medical necessity to minimize future risk from RAC audits?

The answer simply could boil down to the therapy clinical documentation on the chosen G codes and severity modifiers. Instead of making them “add-ons” to the current way therapists record documentation, let them drive a new way of conveying medical necessity and showing the value of getting a professional therapist involved with the case. 

Of course, auditors and payers are not the only ones to review a therapist’s documentation. Physicians, other therapists, other health professionals, patients and family members, and attorneys will have different objectives in reviewing the reports. The therapist must remain conscious of how others will interpret and use this information. Physicians, for example, want direct and to-the-point clinical information. Other therapists have to be consistent in their approach and use of clinical modalities. Still other healthcare professionals need to understand the rationale behind the therapist’s plan of care, plus the goals and the expected outcomes for each patient. Attorneys want a clear picture of the extent of their clients’ injuries and the efforts being taken to allow them to reach their prior level of function. Therapists’ documentation is complex and an essential part of their professional responsibilities – and putting it all together seems to get harder with each new regulation that is passed.

However, with a new approach of making the functional limitation reporting’s G code classifications and severity modifiers the centerpiece of therapist documentation, meeting the needs of the entire potential audience should be simplified.

Therapists long have struggled with documentation. Over 60 percent of therapists still are using pen and paper or transcription, many years into the information age. There’s no question why it is such a challenge for them to stay compliant, with the ever-changing rules and regulations. Medicare has insisted for decades that therapists focus mainly on their patients’ functional difficulties (i.e., daily home and community activities) in their documentation and not so much with the patients’ impairments (i.e., pain, range of motion, strength, balance, posture, coordination, etc.). However, confusion prevails.  

Now, with a new paradigm shift in the way therapists perform clinical reporting, documentation for therapists should become more consistent, compliant and meaningful for everyone. In the long run, this should make it much easier on the therapists.

However, even if streamlined, pen and paper or transcription no longer will be able to keep rehabilitation documentation in compliance with regulations and meeting the informational needs of the various aforementioned audiences. On top of that, documentation regulations differ in each rehab setting (i.e., acute inpatient, sub-acute, skilled nursing facilities, inpatient rehab facilities, home health and outpatient therapy). It has become simply overwhelming for many therapists.

Specialized rehab EMR that integrates with the larger institutional information systems is becoming increasingly essential to maximize efficiency, clinician productivity and profitability while minimizing risks associated with denials/audits and therapist burnout.

About the Author

Gerry Stone is a physical therapist and the founder/chief clinical officer of The Rehab Documentation Company, Inc., makers of ReDoc Software. He served on the Neuro-Muscular panel of American Physical Therapy Association to help to write The Guide to Physical Therapist Practice, Volume 1, (1995-1997).  He has extensive knowledge of the CMS and TJC regulations and billing structures pertaining to rehab settings.

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