Page 209 - Medicare Benefit Policy Manual

Modifier Impairment Limitation Restriction
CI At least 1 percent but less than 20 percent impaired, limited or restricted
CJ At least 20 percent but less than 40 percent impaired, limited or restricted
CK At least 40 percent but less than 60 percent impaired, limited or restricted
CL At least 60 percent but less than 80 percent impaired, limited or restricted
CM At least 80 percent but less than 100 percent impaired, limited or restricted
CN 100 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:

• Uses the severity modifier that reflects the score from a functional assessment tool
or other performance measurement instrument, as appropriate.

• Uses his/her clinical judgment to combine the results of multiple measurement
tools used during the evaluative process to inform clinical decision making to
determine a functional limitation percentage.

• Uses his/her clinical judgment in the assignment of the appropriate modifier.

• Uses the CH modifier to reflect a zero percent impairment when the therapy
services being furnished are not intended to treat (or address) a functional
limitation.

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: