Policy Analysis: Making Sense of G-Codes, PQRS and Other Alphabet Soup New Medicare outcomes reporting requirements can be confusing and complicated. Here are some FAQs to help get you started. Policy Analysis
Policy Analysis  |   March 01, 2013
Policy Analysis: Making Sense of G-Codes, PQRS and Other Alphabet Soup
Author Notes
  • Lisa Satterfield, MS, CCC-A is ASHA director of health care regulatory advocacy.
  • Tobi Frymark, MA, CCC-SLP is associate director of ASHA's National Center for Evidence-Based Practice.
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   March 01, 2013
Policy Analysis: Making Sense of G-Codes, PQRS and Other Alphabet Soup
The ASHA Leader, March 2013, Vol. 18, 16-19. doi:10.1044/leader.PA.18032013.16
The ASHA Leader, March 2013, Vol. 18, 16-19. doi:10.1044/leader.PA.18032013.16
What's a PQRS? Why do I have to report data on the same patients twice? Do I even have to report data?
Ever since significant new outcome reporting requirements for Medicare Part B patients took effect Jan. 1, speech-language pathologists and audiologists have brought many questions about the new requirements to ASHA staff. Here are answers to some of the most frequently asked questions.
Am I required to report outcomes to Medicare?
Whether or not you must report outcomes depends on the kinds of services you provide to specific groups of patients:
  • SLPs who provide services to Medicare Part B beneficiaries in any facility must report outcomes on the claim form (see ASHA's new webpage).

  • SLPs in private or group practice who provide specific services to Medicare Part B beneficiaries with a diagnosis of late effects of a stroke must also report outcomes as part of the Physician Quality Reporting System through a registry approved by the Centers for Medicare and Medicaid Services.

  • Audiologists in private or group practice who provide services to Medicare Part B beneficiaries with a diagnosis of dizziness; benign paroxysmal positional vertigo; or outer ear deformities, injuries or conditions must report outcomes for PQRS on the claim form (see ASHA's step-by-step guide for complete instructions).

How is ASHA's National Outcomes Measurement System related to the outcome measurement requirements?
NOMS has distinct and separate relationships with the two Medicare outcome measurement programs—PQRS and claims-based outcome reporting—for SLPs.
CMS manages both programs, but they are separate entities. Data reported to one program do not translate to the other, nor do the programs share reported data.
  • PQRS. NOMS is a CMS-approved registry for reporting PQRS outcomes related specifically to the late effects of a stroke. SLPs enter their data into the NOMS data collection system and ASHA submits the data on the behalf of the SLP. See ASHA's PQRS webpage for more information about participating in PQRS through NOMS.

  • Claims-based reporting for Medicare Part B. The new requirement that all SLPs report outcomes on the Medicare claim form is not related to PQRS. CMS does not specifically require NOMS participation and ASHA does not submit NOMS data to CMS for the claims-based outcome reporting requirement. Instead, claims-based reporting requires the facility or provider submitting the claim for the service to submit the outcome data using "G-codes" and severity modifiers. Outcome data for this program are based on the NOMS functional communication measures. However, because NOMS was used as a standard in the development of the reporting codes and severity modifiers, SLPs can easily use NOMS to track patient outcomes and as a resource for code and modifier selection and documentation.

Am I ever not required to report outcomes—for example, if I am not recommending treatment?
If you provide services to Medicare Part B beneficiaries, you must always report outcomes on the claim form and be compliant with all reporting requirements by July 1, 2013. If you don't, CMS will return your claims unpaid.
If you bill for an evaluation, you must minimally report current status and a projected goal. If you see the patient for only one visit because treatment is not recommended or because you are referring to another provider, you must report the current status, projected goal and discharge status on the claim. See the ASHA website for a complete list of codes, examples and instructions for reporting.
How do I start?
  • Read the ASHA resources (linked above) with links to CMS guidance on the ASHA website.

  • Consider using NOMS. Participation is a member benefit. Register your organization. To begin using the system, all SLPs in the facility complete a self-study training course.

  • Begin documenting in patients' medical records. You must include in the documentation the alphanumeric G-codes and modifiers, and the tool you used. This documentation is required for all Medicare Part B patients. ASHA, however, recommends documentation for all adult patients, as documentation would be required, for example, if a Part A patient were transferred to Part B billing or if patients with private insurance or Medicaid were also eligible for Medicare Part B.

  • Begin including G-codes and modifiers on the claim according to the instructions. This may require you to use or create a new form. You must be reporting within the program requirements by July 1; ASHA recommends providers begin reporting on any new Medicare patients as soon as possible to ensure they are in the reporting cycle accurately.

  • Register for ASHA Headlines to receive e-mails with the most up-to-date federal and regulatory information as it is released.

Use NOMS to Make Reporting Easier

Participation in the adult component of NOMS—which collects health care data on adult patients—is voluntary and free to ASHA members. By registering, health care organizations agree to collect and submit data to ASHA's national registry. In exchange, participants have access to reports benchmarking their facility's data against national as well as system data, if applicable. ASHA encourages participation in NOMS, as access to more data allows ASHA to advocate for speech-language services and to help CMS make data-driven decisions about payment.

To help NOMS participants comply with the new Medicare claims-based reporting rules, ASHA is developing several NOMS enhancements, including:

  • New G-code converter. When SLPs enter functional communication measure data for a particular patient, NOMS will automatically generate the appropriate reporting codes ("G-codes") and severity modifiers needed for the claim form.

  • New goal-setting feature. SLPs will have access to real-time national benchmarking data based on patient characteristics (for example, diagnosis and severity level) to help set projected goals for patients.

  • Flexible data reporting. A new interim reporting form will allow NOMS participants to collect data at Medicare-specified intervals, in addition to admission and discharge.

For more information about NOMS, visit the NOMS website.

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March 2013
Volume 18, Issue 3