Outcome measures and G-codes

Reliable, ADM In afternoon light

I’m finishing up the May 2013 issue of GeriNotes, the newsletter for the Section on Geriatrics. There is an article “Section on Geriatrics Recommended Outcome Measures for Medicare Functional Limitation/ Severity Reporting” which I found interesting. There is the background/ reporting process for G-codes, the different categories for G-codes, and then the SOC recommended outcome measures for reporting. They have “a list of recommended [emphasis theirs] measures with best evidence, practicality of use, responsiveness, and psychometrics.” This list includes:

Walking speed
Six-minute walk test (or 2 minute or 3 minute version)
TUG and/ or TUG Manual
Five Times Sit-to-Stand and/or 30 Second sit-stand
Sitting Balance Scale
Berg Balance Scale
Patient Specific Functional Scale
Disabilities of the Arm Shoulder and Hand Scale (DASH or Quick-DASH)
Fullerton Advanced Balance Scale
Elderly Mobility Scale
Falls Efficacy Scale – International

What does the list not include? First, I noticed OPTIMAL is missing, despite CMS listing it as one possible tool. Second, there are no recommendations for taking the results from one of the tests and translating that into one of the severity modifiers (CH-CN). I think this is also an issue for OPTIMAL.

I am for using reliable outcome measures. Just as a manual muscle test is variable across practitioners, transfer grades (min/mod/max) can be about the same. I appreciate that the Geriatrics and Neuro sections have developed a toolbox of outcome measures. The question or issue I have in relation to the article is how does a 47/56 on the Berg, a DASH of 61, a FTSTS of 25.3 seconds, or a 6MWT of 1300’ relate to a percent disability. It can’t be a straight cross walk (if the severity modifier is 0-100% and the Berg is 0-56, 28/56 on the Berg is not validated to 50% disability). Also, the Berg measures fall risk, not percent disability. For other outcome measures, what about the situations where there are age-matched norms such as walking speed? Or if they can’t do the FTSTS without using their arms, how does that mark them down in the percent disability? Or what if they improve greater than the MCID but it doesn’t improve their “disability score” (if they are 39% impaired at a CJ, they would need to get better than a 19% improvement to >20% to move into the next category)?

At work we are using the OPTIMAL tool primarily (we can use others so long as we justify our severity modifier in the description section of the G-code of our EMR), and it is the best system available to us. When CMS came out with the new requirements, I thought there would be a silver lining of encouraging us all to use outcome measures more. That silver lining has tarnished after the July 1 deadline. My professional concerns are how CMS will use the data we are all submitting (affecting both the patients and rehab professionals), and if the data we are providing is really accurate (and if it isn’t, is this helping or hindering us). I only have questions, trying to sort all this out in my own mind as I try to be the best therapist I can and look out for the best interests of my patients. Given the lowering reimbursement, the changing caps, and the increasing regulations, I’m not surprised practices are refusing Medicare, going to a cash-based system, or shifting focus entirely.

Addendum: FOTO reminded me that they were also left off the recommended list but are “approved by CMS for several years now.”  Sorry about that!

Photo credit: Reliable, ADM In afternoon light, originally uploaded by swanksalot

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