Functional Pathways wanted you to be aware that you might receive non-compliance alerts for outpatient therapy functional reporting G-Codes and severity modifiers from your MAC.

These alerts do not apply to institutional claims.  There will be no alert messaging for institutional claims between April 1, 2013 and July 1, 2013 per CR 8166.  We wanted you to be aware just in case you receive these alerts.

In the MLN Matters MM8166 effective April 1, 2013 it states that therapy claims with dates of service on and after January 1, 2013 that are processed on and after April 1, 2013 through June 30, 2013—providers will receive a remittance advice (RA) message to alert providers to include the new G-Codes and severity modifiers on future specified therapy claims.  Contractors will send alerts reminding providers to include the new functional limitation G-Codes and the appropriate severity modifiers on future claims through a RA message.

It also says that your carrier or B MAC will continue to process and adjudicate your therapy claims without the required G-codes and modifiers April 1, 2013 through June 30, 2013.

The following Claim Adjustment Reason Code (CARC) and RA Remark Code (RARC) will be used as the alert message:

• CARC 246- “This non-payable code is for required reporting only”
• RARC N565- “Alert: This non-payable reporting code requires a modifier.  Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed.” when nonpayable HCPCS codes G8978 to G8999, G9158 to G9176, or G9186 are submitted without the appropriate modifier (CH-CN)
• RARC N566- “Alert: This procedure code requires functional reporting.  Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed.” when CPT codes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 97001, 97002, 97003, or 97004 are submitted without the nonpayable HCPCs Codes G9878 to G8999, G9158 to G9176, or G9186 and the appropriate modifier.

Please share this information with your business office managers or those who process therapy claims.

To view the MLN Matters Number MM8166, click here