by Jan Weiss
PT, DHS, CLT-LANA
In 2013, the Centers for Medicare and Medicaid (CSM) mandated the use of functional limitation reporting for documentation as a means to base treatment, set goals, and substantiate third-party payment. The selection of appropriate “G” code for patients being treated for lymphedema can be difficult, especially when the individual’s functional level is normal or high. Assistance with documentation can be found using a reference, the International Classification of Functioning, Disability and Health (ICF)1, originating from a document developed by the World Health Organization (WHO) in 1980. The ICF is a classification of human functioning and disability. The diagram below displays the relationship between a health condition, its impact on the individual, and the role that environmental and personal factors have in affecting (dis)ability. Within each of the components listed, domains are grouped according to common characteristics.
Rehabilitation G Codes
When documenting rehab G codes, only the activities and participations (A&P) components are listed. This is because therapies are directed most specifically to improving performance in daily function. Further, the only 3 domains available for rehab within the A&P component are “mobility”, “self-care”, and “other PT/OT primary or subsequent functional limitation.” The “other” domain should only be used for cases in which the primary reason for therapy is NOT directed at improving function; for example, when only wound care will be given. In such cases, use the CH modifier (0% impairment). A recommendation for assignment of G code is to ask the patient what they are having most difficulty performing and determine whether the dysfunction is more appropriately categorized as a mobility or self-care dysfunction. The following section will inform on how to properly select an appropriate G code.
How to Select an Appropriate G Code for a Patient with Lymphedema
Under the components of A&P and within domains of mobility and self-care, further branching details specific functional difficulties that patients with lymphedema may exhibit. Consider the list below in which scenarios of problems are listed for documentation purposes. This is not designed to be a comprehensive list but instead, provide you with some ideas.
1) Changing and maintaining body position — staying in the same position, or moving from one location or structure to another. Example: Difficulty getting into/out of car, bed, bath.
2) Carrying, moving, and handling objects — fine-hand coordination, lifting or carrying objects, or moving objects with legs or feet. Example: Diminished function due to edema-related loss of UE or LE strength, ROM, coordination — patient is unable to lift, push or pull, or manipulate objects due to edema.
3) Walking and moving around — walking, skipping, jumping, running, with or without assistive device. Example: Difficulty walking, stair climbing, or needs to use an assistive device due to the edema.
4) Moving around using transportation. (This one is not included in many functional reporting lists.)
Details not included in most functional reporting lists, but include the following:
1) Washing oneself.
2) Caring for body parts — looking after parts of body that require more than washing and drying. Example: Extra attention must be made to care for skin/nails.
4) Dressing — performing coordinated actions of putting on/off clothing. Example: Difficulty fitting or donning/doffing clothing or shoes; choosing appropriate clothing due to limb size.
5) Eating — performing coordinated tasks of eating food, cutting it, opening bottles and cans. Example: Patients with head and neck cancer-related impairments with difficulty eating or difficulty using silverware.
6) Drinking — taking hold of drink, consuming in a culturally acceptable manner, stirring, pouring. Example: Patients with head and neck cancer-related impairments with difficulty drinking.
7)Looking after ones’ health — ensuring one’s physical comfort, managing diet and fitness, maintaining one’s health. Example: The patient must carry out activities to maintain health and physical well-being (i.e. self- care activities including skin care, managing diet, exercising, wearing compression garments), avoid harms to health (i.e. cellulitis).
Other PT/OT Primary/Subsequent Functional Limitation
Use this category in which the primary reason for therapy is NOT directed at improving function, and use the CH modifier (0% impairment).
How to Select Appropriate Impairment Level
for a Patient with Lymphedema
The use of standardized measures including performance – based on patient self-report instruments, additional patient data, and clinical judgment – are important elements in determining impairment level of functional performance. Impairment levels from 0–100% can be obtained from the scores of many such instruments or with assistance from a conversion calculator such as found at http://www.mediware.com/rehabilitation/tools/item/g-code-conversion-calculator. Functional outcomes from one or more measures are encouraged. For patients with lymphedema, it is optimal to utilize both a functional performance scale (i.e. DASH, LEFS, PSFS) and a condition-specific scale such as the Lymphedema Life Impact Scale (LLIS) to assess the impact of lymphedema on the patient. The LLIS has its own G code calculator to assist in calculating the appropriate modifier and may be obtained from klosetraining.com/resources/education-materials.
International Classification of Functioning, Disability and Health. ICF Short version. Geneva, Switzerland: World Health Organization; 2001.