Urology Coding Alert

Forget the ‘G’ code and you’ll be denied.

When your urologist orders physiotherapy for a female patient with stress urinary incontinence (N39.3, Stress incontinence [female] [male]), don’t forget to assign one of three G codes to the claim:

• G8990 — Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals
• G8991 — ...  projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
• G8992 — ... discharge status, at discharge from therapy or to end reporting.

Don’t expect additional reimbursement for G8990-G8992, however. These codes are used only for data collection purposes, but omitting them from your physiotherapy claims – or using them incorrectly – will lead to denials.

Have a Solid Understanding of When to Use Each Code

This group of G codes is sometimes referred to as “functional limitation” codes because they document that a patient’s ability to perform a particular function is limited. Reporting these codes along with physiotherapy services and codes became mandatory on July 1, 2013.

The codes apply specifically to three types of services:

• Physical therapy
• Occupational therapy 
• Speech-language pathology.

You must report them for any of these services in multiple treatment sites: hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities, rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and private offices of therapists, physicians, and non-physician practitioners.

Which ones you will report depend on which point in the treatment process you are reporting, according to Michael A. Ferragamo MD, FACS, assistant clinical professor of urology with the State University of New York, University Hospital and Medical School at Stony Brook. You should include non-payable G-codes and modifiers on the submitted 1500 or electronic claim forms (a) at the first session; (b) at a minimum of every tenth visit; and (c) at discharge.

“The guidelines state that you must report a G code for the first session and the last, and at least every tenth session, but you can report more often,” Ferragamo says. “Usually there are 4-8 treatment sessions.”

Remember to Include a C Modifier

G codes are “always therapy” codes which require a therapy modifier, according to Pamela R. West, DPT, MPH, of CMS. You have specific “C” modifiers that apply to these codes, known as severity modifiers. They reflect the score from a functional assessment tool or other performance measurement instrument.

Your choices are: 

• CH — 0 percent impaired, limited or restricted
• CI — At least 1 percent but less than 20 percent impaired, limited or restricted
• CJ — At least 20 percent but less than 40 percent impaired, limited or restricted 
• CK — At least 40 percent but less than 60 percent impaired, limited or restricted
• CL — At least 60 percent but less than 80 percent impaired, limited or restricted
• CM — At least 80 percent but less than 100 percent impaired, limited or restricted
• CN — 100 percent impaired, limited or restricted.

“For the physiotherapy of urinary incontinence, most urologists will often use modifier CM, until the patient reaches their therapeutic goal, most often CI,” Ferragamo says.

Practice Coding a Case

Scenario: The urologist sees a female patient with stress urinary incontinence. He documents that the patient experiences leakage 80 percent of the time when she sneezes, laughs, or coughs. The goal of treatment is to decrease the patient’s leakage to less than 20 percent of the time.

Based on the above guidelines, for this case study, you would report the patient’s treatments as follows:

• For the first treatment, report the service with 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility). Attach modifier GP (Services delivered under an outpatient physical therapy plan of care). Also include on a second line G8990-CM-GP to indicate that the patient has just begun therapy and currently has symptoms 80 percent of the time. The final line entry should be G8991-CI-GP to indicate the final goal of therapy.
• If the patient has shown some improvement when she is re-evaluated (such as only having symptoms 50 percent of the time, halfway through treatment), submit 97110-GP for the treatments, as the original treatment. Then add (on a second line) G8990-CK-GP, » indicating the improvement, and then document the expected final goal of treatment with G8991-CI-GP on the third line.
• Upon discharge, when the patient reaches the goal of less than 20 percent urinary incontinence, report 97110-GP on one line and G8992-CI-GP on a second line.

Final reminder: “G” codes do not have reimbursement status, so no payments are made for their reporting.