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Functional Outcomes Reporting for Patients with No Physical Disability
How to Determine Severity Code

The Problem. Functional outcomes reporting became mandatory in Medicare for all outpatient therapy claims on July 1, 2013. The problem is that there are currently few lymphedema measures or outcome tools to measure midline lymphedema (breast, torso, genital, head and neck), and few instruments suitable to measure early lymphedema before it becomes disabling when standard functional disability measures are appropriate.

Medical Treatment or Rehabilitation? Treatment of lymphedema falls into the Medicare definition of services covered that are reasonable and necessary for the treatment of illness or injury, and are not the same as rehabilitation services. For this reason different outcome measures may be more appropriate than the usual functional disability measures. We require instruments that measure severity of the illness or injury directly, rather than by the secondary disability caused by the illness.

What Does the Social Security Act Say? Section 1862(a)(1) of the Social Security Act (the Act) states that payment may be made under Medicare Part A or Part B only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member". In other words, an item or service must be reasonable and necessary for:
diagnosis of illness or injury; OR
treatment of illness or injury; OR
improving the functioning of a malformed body member.

The definition of covered "Medical and Other Health Services" is provided in Section 1861(s) of the Act, and I believe that there is a one-to-one correspondence between the covered medical objectives above and the provider of the provided service below:

"physician's services" §1861(s)(1); OR

"services and supplies ... furnished as an incident to a physician's professional service..." §1861(s)(2)(A); OR

"outpatient physical therapy services and outpatient occupational therapy services" §1861(s)(2)(D).

Separate Policy for Treatment and Rehabilitation? There is a qualitative difference between services provided for the "treatment of illness" and services provided for "... improving the functioning ...". This difference seems to have been lost when HCFA/CMS included all physical therapy (PT) and occupational therapy (OT) services under rehabilitation rules, therefore later subject to therapy caps and exceptions rules. [There was a brief period in the early 2000's when separate lymphedema treatment LCDs existed, separate from the outpatient therapy LCDs, but they have since been retired and the reason for their existence forgotten.]

Impact on Lymphedema Treatment. The blurring of differentiation between treatment of illness and improving functioning of a malformed body member appears to be leading to another blow to lymphedema treatment where therapy reimbursement will be shifting from a "services provided" to a "functional outcomes achieved" schema, and the outcome measures are, so far, all functional disability measures. None of the commonly used functional outcomes reporting instruments is sensitive enough to measure the severity of the underlying lymphedema before it becomes disabling, and when it is most easily treated.

Enter Functional Reporting. The Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 required the Centers for Medicare & Medicaid Services (CMS) to implement a claims-based data collection strategy for outpatient therapy services. CMS announced this collection strategy, known as "Functional Reporting", in the Calendar Year (CY) 2013 Physician Fee Schedule final rule (77 Federal Regulation 68958). Functional Reporting collects data on patient function during the therapy episode of care to understand beneficiary functional limitations and outcomes. Effective January 1, 2013, claims for outpatient therapy services were required to include non-payable G-codes and severity modifiers, which describe a beneficiary's functional limitation and severity level at specified intervals during the therapy episode of care.

How to Report When There Is No Functional Limitation. In its Guidelines for Selecting the G-codes to Report, CMS does recognize that not all therapy is targeted toward treating one of the four functional limitations (i.e. mobility,walking and moving around; changing body position; carrying, moving and handling objects; self care), and they have provided an "Other" category which is appropriate for lymphedema therapy:

Measurement and Treatment Before There is Disability. Current research is leading to the conclusion that it is far better to detect lymphedema as early as possible and intervene to prevent or delay the swelling and destructive tissue changes, than to wait until there is appreciable measurable swelling or disability. Reference Stout's Prospective Surveillance Model which uses a 3% volume change threshold for intervention with compression sleeves, and Zimmermann, who uses MLD on all post-mastectomy patients from day 2 to prevent lymphedema. Sensitive measures of lymphedema, rather than secondary functional deficit, are needed if lymphedema diagnosis can be made and lymphedema therapy effectiveness measured.

Generalized Measurement Instruments. Most, if not all, therapy measures are based on the International Classification of Functioning, Disability and Health (ICF) model. Four instruments used by therapists over the years for evaluating function and disability (AM-PAC, FOTO, OPTIMAL and NOMS) have been suggested for use by CMS (Benefit Policy Manual CMS Publ. 100-02, Chapter 15, §220.3C Physical Therapy Evaluation/Re-Evaluation), however, they may not be sensitive to lymphedema severity in the absence of lymphedema-related functional deficit. Specific lymphedema instruments or lymphedema objective measurements may be more appropriate for measuring the effectiveness of therapy as a component of the treatment of the medical condition before disability.

The ALFP Survey. The following survey, a combined effort of Nicole Stout and Robert Weiss, was implemented as a "Survey Monkey" by the American Lymphedema Framework Project (ALFP) and used to inform therapists on lymphedema functional reporting. The specific items in the survey are listed below. Results of the survey have been embargoed pending publication.

Outcomes Measures.

Informal Survey of Tools Being Used. An informal survey was made at my Reimbursement Issues networking table at the Lymphedema Seminar's Networking and Educational Seminar November 2, 2013 at Rancho Mirage, CA as to the measurement instruments used by lymphedema therapists reporting severity for their patient claims. The following measurement instruments were cited:

New Lymphedema-Specific Measurement Instrument. There was interest in obtaining Dr. Jan Weiss' recently validated Lymphedema Life Impact Scale (LLIS). The Lymphedema Life Impact Scale (LLIS) is an 18-item patient questionnaire that measures the physical, functional, and psychosocial concerns pertinent to patients with lymphedema. This new validated instrument helps measure outcomes in patients with any extremity lymphedema. The Dysfunction Severity Calculator is a quick and easy Excel scoring instrument used in conjunction with the LLIS to automatically calculate percent impairment and assign an appropriate G-code as mandated by Medicare. Computer Requirements: Microsoft Excel, Adobe Reader. Allows use by one brick-and-mortar healthcare facility. Files are sent via email. These tools were created by Klose Training instructors Jan Weiss, PT, DHS, CLT-LANA, and Linda Hodgkins, MS, OTR/L, CLT-LANA.
Send your questions about the LLIS to
Send your questions about the G-Code Calculator to

Conversion From Measurement Score to G-code Severity Modifier. One other useful resource which can be used to convert scores from a number of measurement instruments into CMS Medicare Part B severity G-codes is the Claims-Based Outcomes Reporting (CBOR) G-code Conversion Calculator by Mediware® found on the Mediware web page:


CMS National Provider Call. Preparing for Therapy Required Functional Reporting Implementation in CY 2013. Pamela R. West, Presenter, December 12, 2012.

MediServe Industry Resources Web Page
and G=code Converter

clinicient Functional Limitation Reporting Blog

APPENDIX A   Medicare Benefit Policy Manual CMS Pub. 100-02, Chapter 15 §220.4 - Functional Reporting

220.4 – Functional Reporting
(Rev. 165, Issued: 12-21-12, Effective: 01-01-13, Implementation: 01-07-13)

A. Selecting the G-codes to Use in Functional Reporting.

There are 42 functional G-codes, 14 sets of three codes each, for that can be used in identifying the functional limitation being reported. Six of the G-code sets are generally for PT and OT functional limitations and eight sets of G-codes are for SLP functional limitations. (For a list of these codes and descriptors, see Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6 F.)
Only one functional limitation shall be reported at a time. Consequently, the clinician must select the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment. When the beneficiary has more than one functional limitation, the clinician may need to make a determination as to which functional limitation is primary. In these cases, the clinician may choose the functional limitation that is:

In all cases, this primary functional limitation should reflect the predominant limitation that the furnished therapy services are intended to address.

For services typically reported as PT or OT, the clinician reports one of the "Other PT/OT" functional G-codes sets to report when one of the four PT/OT categorical code sets does not describe the beneficiary's functional limitation, as follows:

In addition, the subsequent "Other PT/OT" G-code set is only reported after the primary "Other PT/OT" G-code set has been reported for the beneficiary during the same episode of care.

For services typically reported as SLP services, the clinician uses the "Other SLP" functional G-code to report when the functional limitation being treated is not represented by one of the seven categorical SLP functional measures. In addition, the "Other SLP" G-code set is used to report where an overall, composite, or other score from an assessment tool that does not clearly represent a functional limitation defined by one of the seven categorical SLP measures.

B. Selecting the severity modifiers to use in functional reporting/documenting.

Each G-code requires one of the following severity modifiers. When the clinician reports any of the following a modifier is used to convey the severity of the functional limitation: current status, the goal status and the discharge status.

ModifierImpairment Limitation Restriction
CH0 percent impaired, limited or restricted
CIAt least 1 percent but less than 20 percent impaired, limited or restricted
CJAt least 20 percent but less than 40 percent impaired, limited or restricted
CKAt least 40 percent but less than 60 percent impaired, limited or restricted
CLAt least 60 percent but less than 80 percent impaired, limited or restricted
CMAt least 80 percent but less than 100 percent impaired, limited or restricted
CN100 percent impaired, limited or restricted

The severity modifier reflects the beneficiary's percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge. In selecting the severity modifier, the clinician:

In some cases the modifier will be the same for current status and goal status. For example: where improvement is expected but it is not expected to be enough to move to another modifier, such as from 10 percent to 15 percent, the same severity modifier would be used in reporting the current and goal status. Also, when the clinician does not expect improvement, such as for individuals receiving maintenance therapy, the modifier used for projected goal status will be the same as the one for current status. In these cases, the discharge status may also include the same modifier.

Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.

C. Documentation of G-code and Severity Modifier Selection.

Documentation of the nonpayable G-codes and severity modifiers regarding functional limitations reported on claims must be included in the patient's medical record of therapy services for each required reporting. (See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6 for details about the functional reporting requirements on claims for therapy services, including PT, OT, and SLP services furnished in CORFs.)

Documentation of functional reporting in the medical record of therapy services must be completed by the clinician furnishing the therapy services:

The qualified therapist furnishing the PT, OT, or SLP services in a CORF


BIRSBody Image and Relationship Scale 
BISSBody Image States ScaleCash (2002)
CARES-SFCancer Rehabilitation Evaluation Syatem–Short FormSchag (1991)
COOPDartmouth Primary Care Coop Information Project  
DAS-24Derriford Appearance Scale  
DASHDisabilities of the Arm, Shoulder and HandGummesson (2003)
DASH/Quick DASH Disability of Arm, Shoulder and HandBeaton (2001)
EORTC-QLQ-30EORTC QoL Questionaire Core Questionaire V.3.0Aaronson (1993)
EORTC-QLQ-BR23EORTC QoL Questionnaire Breast Cancer ModuleSprangers (1996)
FACT-BFunctional Assessment of Cancer Therapy—BreastBeaulac (2002)
FACT-B +4FACT-B + 5 Lymphedema-Specific Questions 
FACT-H&NFACT Head and NeckList (1996)
FLICFunctional Living Index – CancerSchipper (1984)
FLQA-LFreiburg Life Quality Assessment-LymphedemaAugustin (2005)
GCLQ Gynecologic Cancer Lymphedema Questionnaire Carter, Barakat (2010)
HADHospital Anxiety Depression Scale  
ICF ICF Core Set for Lymphedema Viehoff (2012)
IDI-ILA part II Instituto Dermopatico Dell'Immacolata (Italian LE Assn.)  
IOCImpact of Cancer Scale  
LBCQLymphoedema and Breast Cancer QuestionnaireArmer (2003)
LELLower Extremity Lymphedema IndexYamamoto (2011)
LLIS Lymphedema Life Impact Scale Weiss (2013)
LMFA-Y/-O Lymphatic Malformation Function-Youth/-Observer Patrick (2011)
Lymph-ICF Lymphoedema Functioning, Disability and Health Questionnaire Devoogdt (2011)
Lymph-ICF-LL Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema Devoogdt (2014)
LYMPH-Q   Massey, Pusic
LYMQOL QoL measure for lymphedema of the limbs Keeley (2004, 2010)
MDASI-HN MD Anderson Symptom Inventory- Head & Neck Cancer Cleeland (2000)
MSAS Memorial Symptom Assessment Scale Portenoy (1994)
NHP Nottingham Health Profile  
PGWB Psychological General Well Being Index  
QLQ-BCV Quality of Life Breast Cancer Patient Version  
RSCL Rotterdam Symptom Checklist De Haes (1990)
SF-36 Medical Outcomes Study 36-Item Short Form Ware (1992)
telephone survey   Norman (2001)
UEFI Upper Extremity Functional Index Stratford (2001)
UEL Upper Extremity Lymphedema Index Yamamoto (2013)
ULL-27 Upper Limb Lymphedema Launois (2000)
VHNSS Vanderbilt Head and Neck Symptom Survey Murphy (2010)
WCLS Wesley Clinic Lymphedema Scale Mirolo (1995)
WHOQOL-BREF WHO QoL Assessment–Abbreviated Version