Functional Outcome Assessment uses the following G-codes:

Note that some items in the 2 assessment groups are boldfaced while others are not. The highlighted items are the ones that will be used the most commonly. However, when there is a patient that does NOT meet the criteria, the less frequent codes will need to be used.

**************** There is one code in the Functional Outcome Assessment group that is italicized with stars next to its G-code. Medicare requires Chiropractors to clearly show that a Functional Outcome Assessment was performed at least once every 30 days while the patient is under Active Treatment, but for every regular office visit that is in-between the re-exams, Chiropractors must also show that the Functional Outcome Assessment was NOT done.

Each of these categories MUST be reported (shown on your claim) for every Medicare patient for every visit that includes CPT code 98940, 98941, or 98942.

The form must be given to the patient on the initial visit and at least once every 30 days while the patient is under Active Treatment, signified by the use of the AT modifier in the line item billing. Based on the Outcome Assessment form, Medicare expects to see a 10% or greater amount of improvement in the patient’s condition at the end of each month of Active Treatment. If there is less than a 10% amount of improvement over the course of 2 or more months, Medicare considers the treatment to be maintenance care. In a post payment audit, Medicare will require the doctor to refund the payments already made if the care given is deemed to have been maintenance care.

There are several Meaningful Use Measures that require the use of additional PQRS codes in the ChiroSuiteEHR system. Each practice is different so that each will find that only some of these are appropriate for the office. It may not be necessary to use all these codes; just use the ones that are appropriate for the practice and the patient. The PQRS codes required by ChiroSuiteEHR to complete Meaningful Use requirements are discussed in detail in Chapter 18 of this Manual. NOTE that in addition to the PQRS codes, there may also be requirements for specific ICD-9 diagnosis codes, CPT codes, and other items that MUST be present in the patient file. These ChiroSuiteEHR required PQRS codes include

•    Measure # 317 Preventive Care Screening for High Blood Pressure

o  Measure #317 classifies the blood pressure in 3 categories:

§ Normal is when both the systolic and diastolic measurements are normal, that is the systolic is 119 or lower and the diastolic is 79 or lower

§ Pre-hypertension is when either number is slightly abnormal; systolic between 120 and 139; diastolic between 80 and 89 [SIDE NOTE: Medicare has now made almost everyone abnormal, since 120/80 is considered to be normal blood pressure]

§ Hypertension is when either number is significantly elevated; systolic of 140 or higher; diastolic of 90 or higher

o  G8783             Normal, no follow up needed

o  G8950             Pre-hypertension or hypertension with a follow up plan documented

o  G8784             Blood pressure was NOT documented because the patient is NOT eligible (patient already has an active diagnosis of hypertension; or patient refused to be measured; or patient is in a crisis in which taking blood pressure reading would jeopardize the patient

o  G8951             Abnormal blood pressure documented but the follow up is NOT documented because the patient is NOT eligible

o  G8785 Blood pressure was NOT documented and no reason was given

o  G8952 Abnormal blood pressure documented but the follow up is NOT documented, but NO reason is given

•    Measure # 128 for Body Mass Index (BMI)

o  G8420 Calculated BMI normal

o  G8417 BMI above normal and follow-up plan documented

o  G8418 BMI below normal and follow-up plan documented

o  G8422 BMI NOT calculated, patient not eligible

§ Patient is not eligible if

•    On palliative/maintenance care

•    Pregnant

•    Refuses to be measured

•    Any medical reason that doctor documents explaining why BMI is inappropriate

•    Patient is in emergency health situation and checking BMI would result in delay of critical care

o  G8938 BMI calculated, patient not eligible for a follow-up plan

§ Patient is not eligible if

•    On palliative/maintenance care

•    Pregnant

•    Refuses to be measured

•    Any medical reason that doctor documents explaining why BMI is inappropriate

•    Patient is in emergency health situation and checking BMI would result in delay of critical care

o  G8421 BMI NOT calculated, no reason given

o  G8419 BMI calculated outside normal but NO follow-up plan

•    Measure # 64 for Asthma Assessment

o  In addition to showing the appropriate diagnosis (ICD-9 code) and an appropriate examination (CPT) code, 2 CPT II codes must be used.

§ When the patient’s asthma is evaluated, use both

•    2015F Asthma impairment Assessed

•    2016F Asthma risk Assessed

§ When the asthma is NOT evaluated and there is no reason specified, then use the codes with the 8P modifier

•    2015F 8P Asthma impairment NOT assessed, no reason specified

•    2016F 8P Asthma risk NOT assessed, no reason specified

•    Measure # 231 for Asthma Tobacco Use Screening

o  In addition to showing the appropriate diagnosis (ICD-9 code) and an appropriate examination (CPT) code

§ When tobacco use is assessed

•    1031F Smoking status and exposure to second hand smoke in the home assessed

§ When tobacco use is NOT assessed

•    1031F 8P Smoking status and exposure to second hand smoke in the home NOT assessed, no reason specified

•    Measure # 232 for Asthma Tobacco Use Intervention

o  In addition to showing the appropriate diagnosis (ICD-9 code) and an appropriate examination (CPT) code, there are 2 codes that are required when the patient is a smoker or exposed to second hand smoke

§ 4000F or 4001F

•    4000F Tobacco use cessation intervention, counseling

•    4001F Tobacco use cessation intervention, pharmacologic therapy

§ 1032F Current tobacco smoker or currently exposed to second hand smoke

§ When the Cessation Intervention is NOT performed and there is no reason specified, then use the codes with the 8P modifier

•    4000F 8P Tobacco use cessation intervention, counseling NOT performed, reason NOT specified

•    4001F 8P Tobacco use cessation intervention, pharmacologic therapy NOT performed, reason NOT specified

o  In addition to showing the appropriate diagnosis (ICD-9 code) and an appropriate examination (CPT) code,

§ 1033F when the patient is NOT eligible because the patient is a non-smoker and is NOT exposed to second hand smoke

o  G8751 Smoking status and exposure to second hand smoke NOT assessed, reason NOT given

•    Measure # 126 for Diabetic Foot Exam

o  In addition to showing the appropriate diagnosis (ICD-9 code) and an appropriate examination (CPT) code, one of the following PQRS codes should be used

§ G8404 Lower extremity neurological exam performed and documented

§ G8406 Patient NOT eligible for lower extremity neurological exam

§ G8405 Lower extremity neurological exam NOT performed

•    Measure # 134 for Depression Screening

o  G8431 Positive screen for clinical depression with a documented follow-up plan

o  G8510 Negative screen for clinical depression, follow-up plan NOT required

o  G8433 Screening for clinical depression NOT documented, patient not eligible

o  G8940 Screening for depression documented, follow-up plan NOT documented, patient NOT eligible

o  G8432 Screening for depression NOT documented, reason not given

o  G8511 Screening for depression documented, follow-up plan NOT documented, reason NOT given

•    Measure # 226 for Tobacco Use Cessation (NON-asthma patient)

o  4004F Patient screened for tobacco use AND received cessation intervention (counseling or pharmacotherapy)

o  1036F Patient screened for tobacco use and is a NON-user

o  4004F 1P Documentation of medical reason for not screening (for example, limited life expectancy)

o  4004F 8P Tobacco screening or cessation intervention NOT performed, reason NOT specified

Additional specific details about these PQRS codes is available on the Medicare (CMS) website. The data can be downloaded in a PDF format. The specific document is the 2013_PQRS_MeasureSpecManual.pdf which is 637 pages.