Health Information Management

Q/A: What type of documentation is required for the functional limitation codes?

APCs Insider, July 12, 2013

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Q: What type of documentation is required for the functional limitation G-codes? Our therapists say that the documentation of the evaluation and therapy plan will cover the codes and modifiers. Is that correct?

A: Documentation in the patient’s record is critical in order to supporting the codes and modifiers reported for the beneficiary’s individual situation. CMS notes in the Claims Processing Manual, chapter 5, section 10.6.H:

The clinician who furnishes the services must not only report the functional information on the therapy claim, but he/she must track and document the G-codes and severity modifiers used for this reporting in the beneficiary’s medical record of therapy services.

The plan of care and progress notes are important to support the therapy service, but the documentation must be specific to support the code and modifier selection. The code and modifier should be reported in the record as well as on the claim. The Benefit Policy Manual, chapter 15, section 220.4.C, states that the documentation must be completed by the clinician (qualified therapist, physician or non-physician practitioner) who furnished the therapy services.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



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