How to Navigate Six Tricky FLR Scenarios

Happy almost one-year FLR (functional limitation reporting) anniversary! On July 1, you will have been completing functional limitation reporting—hopefully successfully—for a full year. And that deserves a big congratulations. You may not think it’s much to celebrate, but it is. After all, the road here hasn’t been an easy one to traverse. In honor of this upcoming milestone, I thought I’d use this month’s post to talk through six tricky reporting situations, so this next year around will be easier than the last. Here goes:

Scenario 1: A patient stops attending therapy but returns within 60 days for treatment of the same functional limitation.

If a patients stops attending therapy mid-treatment but returns within two months (60 days) to address the same functional limitation, you don’t need to complete a discharge note or submit discharge codes on the patient’s first visit back. Simply resume treating, documenting, and reporting FLR data as if the patient had never left in the first place. However, when that patient first self-discharges, you should complete a quick discharge note, because most practice acts require therapists to complete one for every patient—even if that patient self-discharges. In the quick discharge note, it’s best to include the status of the patient’s primary functional limitation—even though there’s no billable visit associated with the note and you won’t actually submit the FLR data. But that way, you have a snapshot of the patient’s condition when he or she left therapy. Then, if the patient returns within 60 days, you’ll know exactly where he or she left off.

Scenario 2: A patient stops attending therapy but returns within 60 days for treatment of a different functional limitation.

If a patient self-discharges and returns to therapy within 60 days to receive treatment for a different functional limitation, you must discharge the original functional limitation during the patient’s first visit back to therapy. So even though you will bill for an initial evaluation of the new functional limitation, you will submit FLR discharge codes for the old functional limitation on the claim for that date of service. You’ll then begin reporting FLR data for the patient’s new functional limitation on the patient’s next visit.

Scenario 3: A patient stops attending therapy and returns after 60 days for treatment of either the original functional limitation or a new functional limitation.

If a patient unexpectedly discontinues therapy, Medicare will automatically discharge the therapy reporting episode 60 days after the last recorded date of service. At that point, the patient has a clean slate as far as FLR goes. So, if the patient returns to therapy, there is no need to report discharge FLR data for the patient’s original primary functional limitation. Simply perform an initial examination and begin reporting FLR as if you were treating a new patient.

Scenario 4: A patient is receiving treatment from you and he or she presents with a second, unrelated diagnosis.

If a patient is receiving treatment from you—and you’ve already established the patient’s primary functional limitation—but the patient presents with a second prescription for a second, unrelated diagnosis, you have three options: 1.) You can perform a re-examination, add the second diagnosis, and then continue to see the patient for both issues under the same case. If, upon re-examination, you believe that the existing primary functional limitation should remain, then you should include on the visit claim five G-codes—three for a one-time visit (current, projected goal, and discharge statuses for a second limitation) to add the new diagnosis to the case and two more to reflect the new current and goal statuses for the established limitation. However, if you believe that the established primary functional limitation should change as a result of the new diagnosis, you should submit two codes on the re-examination visit claim to discharge the patient’s original primary functional limitation and then two more codes on the next daily note to establish the patient’s new functional limitation. 2.) If you are seeing the patient on different days for each diagnosis (that is, each visit is dedicated to treating only one diagnosis or the other) you’ll need to treat the cases separately instead of combining them into one case. In this scenario, you should designate one of the cases as the “reporting case”—the case that represents the patient’s actual primary functional limitation and the one for which you’ll submit FLR data. Here’s an example:

Patient John is seeing PT Jane for back pain (case 1). His functional limitation is Mobility: Walking & Moving Around. A week later, John presents with a second diagnosis for knee pain (case 2). Jane wants to treat the patient for each diagnosis separately, on different days, so she creates two cases. On her initial evaluation for case 2, Jane decides that John’s primary functional limitation is actually Carrying, Moving & Handling Objects, so she reports discharge codes for John’s original primary limitation (Mobility: Walking & Moving Around). Then, on the next daily note, regardless of which case she’s treating, Jane will document the new functional limitation G-codes for Carrying, Moving & Handling Objects. The ten-visit count begins when she documents the new functional limitation reporting codes—and the count is shared between both cases. So Jane must make sure she completes a progress note with functional limitation reporting data on or before John’s tenth visit. Alternatively, if Jane believes that John’s primary functional limitation is still the one he originally presented with (Mobility: Walking & Moving Around), she’ll report FLR for the second limitation (Carrying, Moving & Handling Objects) on the initial evaluation as if it were a one-time visit by submitting three sets of codes: current, goal, and discharge status G-codes along with corresponding severity modifiers for each. She’ll then continue to report FLR as normal for Mobility: Walking & Moving Around. In both situations, Jane would weave elements of her treatment plan for the patient’s primary functional limitation into the other case to ensure that the patient is able to achieve the best possible results.

3.) If you believe that the patient would be better off receiving treatment for his or her new diagnosis from another physical therapist in your clinic, then the second therapist should open a separate case and begin therapy. In this scenario, both therapists should work together to determine which of the diagnoses represents the patient’s primary functional limitation. If you both decide the original diagnosis remains the primary functional limitation, you will continue to report functional limitation data as normal and the second therapist will complete FLR for the second limitation as if it were a one-time visit by submitting three sets of codes: current, goal, and discharge status G-codes along with corresponding severity modifiers for each. If you both decide that the new diagnosis is the patient’s primary functional limitation, the therapist treating the new diagnosis will discharge the original limitation during the initial examination for the new diagnosis and record the current and projected goal statuses and the corresponding modifiers for the new primary limitation on the patient’s next visit. Because you’ll only submit FLR data for the patient’s primary functional limitation, both therapists should collaborate to ensure they are working toward the same functional limitation goal. For example, if the first therapist is addressing a mobility limitation, but both therapists agree that self-care is actually the patient’s primary limitation, then both therapists must incorporate treatment elements that will help the patient progress toward his or her self-care goals. If you’re wondering why this is the case, think about it this way: Even though the patient has two separate cases with two separate therapists, Medicare sees only one patient with one limitation and one visit count. Because of this, the patient will likely reach his or her tenth visit—when FLR progress is due next—before either therapist has seen the patient ten times. Here’s an example similar to the one above, but with two therapists:

Patient John sees PT Jane for knee pain (case 1). Joe’s primary functional limitation is Mobility: Walking & Moving Around. A week later, Joe comes to the same clinic to see PT Bob for back pain (case 2). Jane and Bob meet to discuss the cases and both agree that John’s primary functional limitation is actually Carrying, Moving & Handling Objects. On the initial evaluation for case 2, Bob includes the discharge G-codes for the original primary functional limitation (Mobility: Walking & Moving Around). As a result, the discharge codes will go out on Bob’s evaluation claim. Whichever therapist—Bob or Jane—completes the next daily note will record John’s current and goal status G-codes and corresponding severity modifiers for the new primary functional limitation (Carrying, Moving & Handling Objects). The ten-visit count begins with the documentation of those G-codes—and that count is now shared between both Bob and Jane. On the tenth visit, Bob or Jane (whoever is seeing the patient on that date of service) must complete a progress note that includes FLR. If whoever sees John on that date forgets to complete FLR, no claims following that visit—regardless of case or therapist—will be reimbursed. To avoid confusion, you may wish to structure the patient’s appointment schedule so that the therapist who is treating the patient’s primary functional limitation completes all FLR progress notes. In this particular example, Bob would need to complete FLR on or before John’s tenth visit—and remember, completing a progress note resets the visit count.

Scenario 5: A patient is receiving treatment from you on one case and from another therapist in your clinic who has a different speciality (e.g., you’re a PT and he or she is an OT) on a second case.

In this situation, each of you would report FLR data individually, completely independent of one another. When a patient receives treatment for two concurrent cases in two separate disciplines, FLR can occur simultaneously and with two different functional limitations. For example, you, the PT, could treat and report on Mobility: Walking & Moving Around at the same time that the OT in your clinic treats and reports on Carrying, Moving & Handling Objects.

Scenario 6: You’re receiving denials even though you’re doing everything right.

Unfortunately, Medicare still has more than a few kinks to work out in the functional limitation reporting process. So if you’re doing everything correctly and you’re still receiving denials, here’s what you can do:

  1. Call your local MAC—and keep checking their website as many local MACs have been posting regular FLR updates.
  2. If you’re an APTA Member, submit a complaint form here. Representatives of the APTA are meeting with CMS pretty frequently to discuss FLR issues and resolutions, and the more information you can provide them, the better prepared they’ll be for these discussions. You also can check the APTA’s website for updates.
  3. Contact your EMR. They should not only understand all these wonky reporting scenarios, but they should be doing something about them in their system as well. You could be doing everything right, but if your EMR isn’t, then all your effort might be for nothing.

Have you run into any especially tricky FLR reporting scenarios? How have you handled them? Tell us in the comments section below.

About the Author

Heidi Jannenga, PT, MPT, ATC/L, Founder and COO of WebPT

As Chief Operating Officer, Heidi leads the product strategy and oversees the WebPT brand vision. She co-founded WebPT after recognizing the need for a more sophisticated industry-specific EMR platform and has guided the company through exponential growth, while garnering national recognition. Heidi brings with her more than 15 years of experience as a physical therapist and multi-clinic site director as well as a passion for healthcare innovation, entrepreneurship, and leadership.

An active member of the sports and private practice sections of the APTA, Heidi advocates for independent small businesses, speaks as a subject matter expert at industry conferences and events, and participates in local and national technology, entrepreneurship, and women-in-leadership seminars. Heidi is a mentor to physical therapy students and local entrepreneurs and leverages her platform to promote the importance of diversity, company culture, and overall business acumen for private practice physical therapy clinics.

Heidi was a collegiate basketball player at the University of California, Davis, and remains a life-long fan of the Aggies. She graduated with a BS in Biological Sciences and Exercise Physiology and went on to earn her MPT at the Institute of Physical Therapy in St. Augustine, Florida. When she’s not enjoying time with her daughter Ava, Heidi is perfecting her Spanish, practicing yoga, or hiking one of her favorite Phoenix trails.

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