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New G-code reporting on Home Health Claims


Home Health claims will need to report additional and more specific data for the therapy and nursing visits on episodes beginning on or after January 1, 2011.

Currently Home Health claims report the following existing HCPCS codes for Therapy visits:

G0151 – Physical Therapists

G0152 – Occupational Therapists

G0153 – Speech Language Pathologists

These codes are being updated to include descriptions which indicate these services are provided by a “qualified” physical or occupational therapist or speech language pathologist. 

Additionally, two new G-codes are being added to incorporate the reporting of physical therapy and occupational therapy services provided by a “qualified therapy assistant”:

G0157 – Services performed by a qualified physical therapist assistant

G0158 – Services performed by a qualified occupational therapist assistant.

Furthermore, three additional G-codes are being added to establish delivery of therapy maintenance programs by “qualified” therapists:

G0159 – Services performed by a qualified physical therapist to establish or deliver a physical therapy maintenance program

G0160 – Services performed by a qualified occupational therapist to establish or deliver an occupational therapy maintenance program

G0161 – Services performed by a qualified speech-language pathologist to establish or deliver a speech-language pathology maintenance program.


Finally, this update includes a revision of existing codes for skilled nursing services, and the addition of three new G-codes to report the management and evaluation of the care plan, observation of the patient condition, and training and education of patient/family/caregivers.

G0154 – Direct skilled services of a LPN or RN

G0162 – Skilled services by an RN only, for management and evaluation of the plan of care

G0163 – Skilled services by LPN or RN, for observation and assessment of patient’s condition

G0164 – Skilled services by LPN or RN, in training and/or education of patient, family member or caregiver. 

describe the imageCMS has clarified they recognize the nurse or therapist may provide more than one of these new codes in the course of a single visit; however, the HHA must not report more than one G-Code per visit regardless of the variety of services provided during the visit.  The G-Code reported should reflect the service for which the clinician spent most of their time.

Also important to note: these changes do NOT reflect changes in Hospice reporting even though the descriptions for the codes indicate “Hospice” as well.


Can some one give me some examples of when maintenance therapy would be used in a home health setting?
Posted @ Monday, January 10, 2011 11:48 PM by Denise Buchholz, MPT
The National Association for Home Care & Hospice (NAHC) has provided additional clarification from the Medicare Benefit Policy Manual in their Q&A documents at  
E. Maintenance Therapy Where repetitive services that are required to maintain function involve the use of complex and sophisticated procedures, the judgment and skill of a physical therapist might be required for the safe and effective rendition of such services. If the judgment and skill of a physical therapist is required to safely and effectively treat the illness or injury, the services would be covered as physical therapy services. 
EXAMPLE: Where there is an unhealed, unstable fracture that requires regular exercise to maintain function until the fracture heals, the skills of a physical therapist would be needed to ensure that the fractured extremity is maintained in proper position and alignment during maintenance range of motion exercises. 
Establishment of a maintenance program is a skilled physical therapy service where the specialized knowledge and judgment of a qualified physical therapist is required for the program to be safely carried out and the treatment of the physician to be achieved. 
EXAMPLE: A Parkinson's patient or a patient with rheumatoid arthritis who has not been under a restorative physical therapy program may require the services of a physical therapist to determine what type of exercises are required to maintain the patient's present level of function. The initial evaluation of the patient's needs, the designing of a 
maintenance program appropriate to their capacity and tolerance and the treatment objectives of the physician, the instruction of the patient, family or caregivers to carry out the program safely and effectively and such reevaluations as may be required by the patient's condition, would constitute skilled physical therapy. 
While a patient is under a restorative physical therapy program, the physical therapist should regularly reevaluate the patient's condition and adjust any exercise program the patient is expected to carry out alone or with the aid of supportive personnel to maintain the function being restored. Consequently, by the time it is determined that no further restoration is possible (i.e., by the end of the last restorative session) the physical 
therapist will already have designed the maintenance program required and instructed the patient or caregivers in carrying out the program.
Posted @ Wednesday, January 12, 2011 9:11 AM by Cheri Whalen
The handouts from your PPS Final Rule 2011 state "Changes apply to episodes ending January 1, 2011. However, the Cahaba website states G-codes should be used for episodes beginning on or after January 1, 2011. Can you clarify this?
Posted @ Thursday, January 13, 2011 10:00 AM by Sherri
Thank you Sherri for pointing it out. It should be episodes BEGINNING ... I will update the handout
Posted @ Thursday, January 13, 2011 11:03 AM by Cheri Whalen
As a followup... I went back to the regulations, and it does indicate "These regulations are effective on January 1, 2011". What has happened since the issuance of the regulation were clarifications from CMS regarding the implementation of the regulation. In those phone calls and documents, they have indicated the new regulations take effect with Episodes BEGINNING after 1/1/2011. (Prior year updates included episodes ENDING.) I am not going to update the handout at this time; however, I will make an edit to note this change. Thank you again for pointing it out.
Posted @ Thursday, January 13, 2011 11:25 AM by Cheri Whalen
I have several examples of maintenance therapy now but I am wondering if using the maintenance therapy g-codes benefits a home health agency. Are these codes only for tracking purposes? to try to keep patients out of the hospital? Are these maintenance g-codes mandatory to use or just an option? I have contacted the APTA but have not heard back an answer yet.
Posted @ Thursday, January 13, 2011 9:02 PM by Denise Buchholz
Denise - CMS is not providing additional reimbursement for maintenance therapy, nor are they advocating for providers to start providing these kinds of services if you have not in the past. CMS is trying to get a better understanding of the therapy visit needs so they can make appropriate changes in the future to the threshold payments. If your therapy services don't fall into a "maintenance category" (as I noted in a prior comment) then I would expect you do not need to use the new codes. 
If your company is looking to provide maintenance therapy, then you should be using these codes to show a greater level of detail for CMS.
Posted @ Friday, January 14, 2011 8:22 AM by Cheri Whalen
I am confused. So this is optional for the new G codes for both therapies and nursing?
Posted @ Saturday, January 15, 2011 5:07 PM by Tammy
Tammy - The new G-codes more accurately describe the types of service provided to the patient. For example, just as you would use any new diagnosis code which would more accurately reflect a patient condition; you should use these new G-codes to accurately represent the service provided during a visit.
Posted @ Saturday, January 15, 2011 5:36 PM by Cheri Whalen
What's the best way to update my clinical staff? I can't seem to find any materials that can make it easy for them to understand.
Posted @ Wednesday, February 09, 2011 1:55 PM by AMANDA
There are 2 really good (free) podcasts on maintenance therapy and reassessments on the home health web page of the APTA. You do not have to be a memeber to listen to them. They both provide a good amount of information and answer a lot of questions.Here is the web address: 
Posted @ Wednesday, February 09, 2011 3:04 PM by Denise
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