Demystifying Medicare Functional Limitation G Codes

The final July 1 deadline for reporting Functional Limitation Ratings is fast approaching. I have already expressed my opinion in prior blog articles about the flaws in this requirement, but that does not really matter much, since it is the law of the land. This past week, we released a set of features in Insight that make the process for including Functional Reporting Classifications and Severity Modifiers on your documentation and claims easy to do.  As July 1 approaches, and this testing phase ends, we are monitoring claims remarks to make sure that claims for your Medicare patients will not be rejected. That is the easy part.

More difficult is assigning a meaningful impairment rating to your patients. So I have been focusing my efforts to see how we can make complying with this process easier for Clinicient users. 

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I have reviewed transmittals, articles, slide presentations and transcripts from CMS, and similar resources from the APTA to learn more about these requirements and guidelines so I can give our users practical information on assigning impairment ratings.

While I have found reams of information on the mechanics of submitting the Functional Classifications and Impairment Ratings on claims and including that information on your clinical documentation; there is very little practical information on assigning an Impairment Rating for your patients in your clinical documentation.

Presentations from the APTA and from CMS both recommend using widely accepted “Functional Assessment Tools” to determine a current impairment rating. Two of the key slides from the CMS presentationfrom National Provider Call December 12, 2012 presented by Pamela R. West, DPT, MPH are included here.

The APTA has published an article on translating OPTIMAL scores to the Medicare Impairment Ratings.  Others have offered conversion tables or calculators to mathematically convert widely accepted Functional Assessment Tools into Medicare Impairment Ratings.

Mathematically converting common Functional Assessment Tool Scores to Impairment Ratings is relatively easy, and the information from CMS and the APTA seems to indicate that this method may be used to at least get you “in the ball park” to establish an impairment rating.

For your convenience, we have created some of the common Functional Assessment Tool Scores that are already converted to Impairment Ratings for your use:

  • Oswestry Modified for Medicare Impairment Ratings
  • Neck Disability Index Modified for Medicare Impairment Ratings
  • Shoulder Pain and Disability Index Modified for Medicare Impairment Ratings
  • Lysholm Scale Modified for Medicare Impairment Ratings
  • Lower Extremity Functional Scale Modified for Medicare Impairment Ratings
  • DASH Score Modified for Medicare Impairment Ratings
  • Quick DASH Modified for Medicare Impairment Ratings
  • Upper Extremity Functional Scale Modified for Medicare Impairment Ratings

Please email me if you would like these modified Functional Assessment Tools exported to your database, or if you have another widely accepted tool that you would like converted for Medicare Impairments. We would be happy to look at those instruments and modify them for you.

As we gain more guidance about the use of these tools, we will continue to share that information with you.

[Preparing for Therapy Required Functional Reporting Implementation in CY 2013; National Provider Call December 12, 2012. Presented by: Pamela R. West, DPT, MPH Centers for Medicare & Medicaid Services, Center for Medicare Hospital and Ambulatory Payment Group, Division of Practitioner Services.

Excerpt from Transcript explaining Slide 12:

“…you would use the severity modifier that reflects the score from a functional or outcome assessment tool or other performance measurement instrument as appropriate. In cases where the therapist uses multiple assessment tools or measurements tool during the evaluative process to inform clinical decision-making, clinical judgment is used to combine these results to determine a functional limitation percentage. And the third bullet, the therapist can use their clinical judgment in the assignment of an appropriate modifier. Therapists will need to document in the medical record how they made this modifier selection so that the same process can be followed at succeeding assessment intervals.”

Copyright © 2012, 2006,
2005 American Physical Therapy Association. All rights reserved.

Claims Based Outcomes Reporting Calculator. Mediware Information Systems.


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