Understanding the Use of G-Codes
by Patricia Jump, RN, BSN
New G-codes were effective on the home health claim beginning January 1, 2011. Comprehensive/OASIS assessments performed by nursing are not and have not been a covered service and are not billable to Medicare; therefore there is no G-code for billing them.
Choosing the Correct Code
One of the more challenging components of the new G-codes for nursing is selecting the correct code. CMS has instructed providers to use only one G-Code per visit. Often times, clinicians perform more than one skill during the course of a visit. Initially, CMS instructed providers to use the code reflecting the service which the clinician spent the most time completing. However, CMS' instructions for using "time" as the sole criterion for determining the primary reason for the visit was changed in the MLM article to "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 primary reason for the visit, which typically would be the service which the clinician spent most of his/her time."
Using time as the sole criterion for determining the primary reason for the visit may not accurately reflect the acute care needs of patients served by home health agencies. The purpose of collecting the additional G codes is to understand the types of services home health patients require.
General guidance in choosing the various codes includes the following:
G0154 Direct skilled services of a licensed nurse (LPN or RN)
• Medication Administration (IV, IM, Subq)
o Document medical reason why medication can't be given orally
• Insulin injections if client is physically or mentally unable to self-inject & no other person is able and willing to do it
o Prefilling of syringes is not considered skilled
• Frequency & duration of visits match standards of medical practice (i.e.: B 12 with specific anemia's - pernicious, megaloblastic, macrocytic, fish tapeworm anemia's; certain GI disorders, & neuropathies and generally administered monthly)
• Catheters - insertion and sterile irrigation in selected patients
• Wound Care when the skill of licensed nurse is needed to provide safe and effective care
o Size, depth, nature of drainage, condition and appearance of surrounding skin need to be part of the clinical findings and documentation
G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care
• Rarely used
• Patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health when there is a barrier to the current medical plan of care
• Complexity includes services, issues, equipment, treatments, medications
• Recovery or medical safety cannot be assured unless the total care is planned and managed by a RN
• Real or potential external factors that complicate the patient's recovery or overall medical treatment, or that threaten the patient's safety in the home environment
• Care plan needs to include measurable and time-specific goals, objectives, planned interventions and outcomes requiring change and frequent adaptation
• Once the treatment regimen under the care plan is stable, the patient should be discharged
• COMPLEXITY is key
• Physician (not agency) must write paragraph describing client's clinical need for management and evaluation and the paragraph must appear immediately preceding the physician's signature
G0163 Skilled services of a licensed nurse (LPN or RN) for the observation and assessment
• Monitoring of an individual's condition, health status, symptoms, progress etc by a registered nurse to determine if the medical treatment requires modification of treatment or procedures
• High likelihood for change in condition
• NEW condition or a CHANGE in a current condition or treatment which places the individual at risk of developing complications
• Reasonable potential for complications, further acute episodes or changes in condition (unstable)
• Generally a short episode of care - only until treatment regimen is stable
• Nurse is monitoring something measurable that requires the skill of a RN
• Observations are being reported to the MD
• Observation and assessment will likely result in changes to the medical treatment (treatment is modified as result of nurse findings)
• Just measuring and finding is not enough - something must be done - the treatment must be changing
• Discharge when stable if this is the only reason for visits.
G0164 Skilled services of a licensed nurse (LPN or RN), in the training and/or education of a patient or family member.
• Consider patient's functional loss, illness or injury
• Consider previous teaching - medical record should document the reason re-teaching or retraining is required
• Generally a short episode to complete teaching
• Not covered if not trainable (i.e.: Advanced Alzheimer's)
• Identify knowledge or skill deficit and connect it to the illness
• Identify limitations affecting teaching/response
o These limitations define the parameters that affect the teaching and response. Example: The patient has a hearing impairment.
• Develop/implement teaching plan to correct or minimize knowledge or skill deficit
• Identify a goal (what the patient will learn), determine a target date, and define interventions to accomplish the goal.
• Evaluate/document response to & progress with identified knowledge or skill deficits
• Identify a diagnosis that connects with the patient's learning need.
• Detail medications, procedures, safety measures, other items of care, which will be part of the teaching plan.
• Document teaching interventions and client response to interventions
Communicating the Correct Code
It is important to set up a system such that not only is the correct code chosen by the nurse completing the visit but the code selection is then communicated to the appropriate billing staff to be included on the home health claim. This may be quite simple for providers using an electronic health record but some providers continue to use paper clinical records. For those providers, a paper system needs to be implemented to make sure there is good communication between the clinician and the billing department.
Auditing for Correct Codes
It will be important to establish an ongoing auditing process to ensure accurate coding. Ideally, this would be an "in-time" audit process whereby codes are verified prior to sending in the claim. Written instructions will be important to ensure consistency between auditors. For example, there needs to be a cross-check with payroll, scheduling and billing to ensure that when a therapy assistant is scheduled and completes a visit, the correct G-code is placed on the claim.
Additionally, it may be beneficial to create an audit form to verify the various nursing codes. One concern about the various nursing codes is that external reviewers such as the fiscal intermediary will deny codes when documentation does not support the specific nursing code. If a certain code is in error or documentation does not strongly support the selected G-code, the auditor and the clinician need to meet for discussion and if needed, remedial training for the clinician. An audit form could be in any format that works for the provider. One suggested format is found in the table below. The full audit tool would, of course, include all of the G-codes.
Nursing Services are described in the Medicare Benefit Policy Manual, Chapter 7, Section 40.1.2 http://www.cms.gov/manuals/Downloads/bp102c07.pdf.
Therapy documentation, as with all documentation, needs to substantiate the need for the therapist. To be covered, the skilled services must also 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. The development, implementation, management, and evaluation of a patient care plan based on the physician's orders constitute skilled therapy services when, because of the patient's condition, those activities require the involvement of a skilled therapist to meet the patient's needs, promote recovery, and ensure medical safety.
While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis or prognosis should never be the sole
factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel. The services must be provided with the expectation, based on the assessment made by the physician of the patient's rehabilitation potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time
Details for comprehensive documentation can be found in the Medicare Benefit Policy Manual, Chapter 7, http://www.cms.gov/manuals/Downloads/bp102c07.pdf
Therapy codes are:
• G0151 Physical Therapist
• G0152 Occupational Therapist
• G0153 Speech‐Language Pathologist
• G0157 Physical Therapist Assistant
• G0158 Occupational Therapist Assistant
Maintenance therapy should help the patient maintain function and involve the use of complex and sophisticated procedures, as well as the therapist's judgment and skill. The clinical record should identify the particular function at risk and show that the program requires the skills of a therapist since therapy assistants may not provide maintenance therapy.
Documentation must include the design of the program, the instruction of the beneficiary, family, or home health aides, and the necessary infrequent reevaluations of the beneficiary and the degree that the specialized knowledge and judgment of a physical therapist, speech-language pathologist, or occupational therapist is required. The amount, frequency, and duration of the services must be reasonable.
In order to meet these criteria, the skill level required would indicate the visits should be performed by the qualified therapist and not a therapist assistant. This is why the new G-Codes related to maintenance are limited specifically to PTs, OTs and SLPs. Maintenance codes include:
• G0159 - Physical therapy maintenance
• G0160 - Occupational therapy maintenance
• G0161 - Speech-language pathology maintenance
Maintenance Therapy is discussed in the Medicare Benefit Policy Manual, Chapter 7, Section 40.2.2 http://www.cms.gov/manuals/Downloads/bp102c07.pdf.
©2011, Patricia Jump. All rights reserved.
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