No one likes feeling like they are making a mistake, especially when dealing with something as important as accurate coding. Recently, a certain set of codes (the Therapy Functional Reporting G-Codes [non-payable]) and the way some hospitals’ billing systems process them have left many coders scratching their heads. Here, I’ll do my best to set the record straight.
In January 2013, CMS introduced 42 Therapy Functional Reporting G-codes (non-payable). These G codes are to be reported in conjunction with therapy services (physical, occupational, and speech). CMS also introduced seven complexity/severity modifiers to be used with these G codes.
With APCs, these G codes were assigned a status indicator of “E.” Under OPPS, codes assigned this status indicator have a payment status of “Not paid by Medicare when submitted on outpatient claims (any outpatient bill type).” The bottom line for these codes is that they receive an OCE edit 028, a line item rejection (LIR): “Code not recognized by Medicare for outpatient claims; alternate code for same service may be available.”
For some hospitals, when an edit like edit 028 surfaces, the billing system will not complete processing the claim for submission. This can cause rework and, for some, delayed payment. No one likes these outcomes, especially when the claim is being coded properly according to regulations.
So don’t think you are doing something incorrect. The OCE was designed to function this way. While there is no instant fix, I recommend speaking with your billing systems or APC grouping vendor to see if there is anything they can do to help with this situation to reduce your effort and frustration.
Dave Fee is the Outpatient Products Marketing Manager with 3M Health Information Systems.