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Outpatient Facility Coding Alert


Here's How to Handle Extra Evaluations When Reporting Functional Limitation

Hint: Now you can report separate evaluations on progress report day.

As the new functional limitation reporting (FLR) requirement for Medicare patients speeds ahead, more questions than answers are surfacing. You can only report one functional limitation for a reporting episode. However, functional limitation reporting is required any time you’re reporting an evaluative or re-evaluative procedure on a claim.

That begs the question: How do therapists code for the additional evaluations and re-evaluations if they’re reporting the patient’s primary functional limitation?

“Until now, you couldn’t do both on the same day,” explains Rick Gawenda, PT, president and CEO of Gawenda Seminars & Consulting.

This situation, however, can easily happen.

“In some cases, patients may present with a second or additional diagnosis when they are already being treated under an active physical therapy plan of care,” says Heather Smith, PT, MPH, program director of quality health for the American Physical Therapy Association.

To set the record straight, Centers for Medicare & Medicaid Services (CMS) recently added clarification on this topic to its existing FLR FAQ document, Smith notes. See item A14 at

Think Two-Plus-Three

CMS instructs therapists to report the usual two codes (current goal status and projected goal status) on the primary functional limitation. Then, report the evaluative procedure for the separate issue as a one-time visit. That means report all three G-codes (current goal status, projected goal status, and discharge status) for your evaluation.

Here’s a clinical example from Gawenda: Suppose you perform an evaluation on Oct. 30 for a Medicare patient with osteoarthritis of the knee. You select mobility as the functional limitation category, and you report the G-code for current status and the projected goal status of the mobility. The patient arrives for a follow-up session on Nov. 13. It’s her 10th visit, so you’re due for a progress report and accompanying G-codes.

The kicker: The patient brings a new order from her doctor for right shoulder impingement.

What to do: Go ahead with the shoulder evaluation and choose an appropriate FLR category (e.g. self-care). Then, continue to work on the knee and write your progress report. Key: Report G-codes for everything. “According to the CMS clarification, in this case, you would report all three G-codes on self-care for the shoulder and continue to report the two G-codes for the knee,” Gawenda explains.

If you were not due for a progress report or otherwise required to report G-codes on the primary functional limitation, then you would only report the three G-codes for the eval.

Remember, “billing an evaluation code will mandate you report G-codes,” Gawenda says.

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