Clinical Profiles of Functional Impairment Measurement Used for G Code Reporting in Outpatient Rehabilitation Presented by: Bob Habasevich, MS PT VP Provider Quality and Performance Improvement Objectives Describe clinical discipline use patterns in choice and use of functional measures to comply with CMS G code reporting requirements for outpatient rehabilitation services. Identify discipline variation in functional limitation measurement selection and reporting. Discuss current clinical practice variation when linking goals of outpatient therapy to value based purchasing initiatives. 1
Methods Functional Limitation Reporting was implemented on January 1, 2013 and the payment adjustment phase was scheduled to be effective July 1, 2013. The CBOR G Code Modifier Calculator was designed to add convenience and consistency to the requirement of performing calculations; converting assessment scores to severity code modifiers as dictated by CMS Claims Based Outcomes Reporting (CBOR) for Medicare Part B claim submissions. Mediware created the conversion calculator to help score and report patient status appropriately. The calculator has been available online since January 2013 and as a downloadable app for iphones and Android devices since September 2013. To date, the calculator has been used more than 149,000 times to convert more than 104 standard clinical measures used for severity modifier conversion. Analysis of calculator use has been tabulated and presented by frequency of use for PT, OT and SLP. Measurement instruments were mapped to G Code definitions for therapy goals. Functional Impairment Dilemma Care Delivery Model Problem Goal Intervention Payment Model Classification Measurement Treatment / Objective Effectiveness Outcome VALUE? FFS Caps Bundle Risk 2
The Ziggy Theorem + Patient oriented outcomes are the focal point of health care. "Doin' stuff" requires being alive (survival) and having the capability to perform activities. + These objectives are quantifiable and can be represented in indices that combine life expectancy with health related quality of life.. Kaplan RM, The Ziggy theorem Health Psychol. 1994 Nov;13(6):451 60. Middle Class Tax Relief and Job Creation Act of 2012 Section 3005 Outpatient Therapy Caps extends the therapy caps exceptions process extended to the hospital outpatient department setting required to collect data to assist in reforming the payment system for therapy services improvements to the outpatient therapy benefit to reflect the individual needs of patients CBO estimates this provision would increase spending by $700 million from 2012 through 2022 Outpatient Therapy Services three separate categories of clinical services that aim to improve and restore function that patients have lost after an illness or injury and to help patients maintain improved function: physical therapy, occupational therapy, and speech language pathology services Prepared by the Committees on Ways and Means and Energy and Commerce Staff, February 16, 2012 3
G Codes Claims Based Outcomes Reporting (CBOR) + This five (5) year project is intended to support payment reform with outcome based data. This is strictly a data collection effort and no other uses beyond analysis have been published. + a loose, non standardized approach to trying to assess a beneficiary s functional limitation N. Beckley 4
G Code Categories Functional Reporting Current Goal Discharge PT/OT Mobility: walking & moving around G8978 G8979 G8980 Changing & Maintaining Body Position G8981 G8982 G8983 Carrying, Moving & Handling Objects G8984 G8985 G8986 Self care G8987 G8988 G8989 Other PT/OT Primary G8990 G8991 G8992 Other PT/OT Subsequent G8993 G8994 G8995 SLP Swallowing G8996 G8997 G8998 Motor Speech G8999 G9186 G9158 Spoken Language Comprehension G9159 G9160 G9161 Spoken Language Expression G9162 G9163 G9164 Attention G9165 G9166 G9167 Memory G9168 G9169 G9170 Voice G9171 G9172 G9173 Other Speech Language Pathology G9174 G9175 G9176 http://www.cms.gov/outreach and education/medicare learning network mln/mlnproducts/downloads/g codes chart 908924.pdf G Code Reporting Intent Clarify to understand the disorder or disease conditions treated by PTs, OTs and SLPs by describing the therapeutic goals to modify functional impairment and quantifying resulting changes with clinical measures used in rehabilitation. 5
G Code Reporting + Requirements FLR program was created through a provision in the Middle Class Tax Relief and Job Creation Act (2012) that mandated the collection of information regarding the beneficiaries function and condition Severity Modifiers + Therapist determined percent of impairment + Reflects the score of a functional assessment tool or other appropriate performance measurement + Uses clinical judgment to combine results of multiple measures or the therapist s judgment alone to determine a functional limitation percentage + The measurement instrument used to determine the percent impairment is not reported to CMS 6
Impairment Conversion Calculation + The score of an instrument is converted to percent by dividing the test score results by the best possible score and multiplying by 100 to obtain a percentage. + The resulting value is applied to the CMS defined lookup table to obtain the severity modifier code. + This approach to defining patient impairment does not enable comparison of converted scores across patients measured with different instruments. Classification of Function + Common Language + Definition + Schema and Structure + ICF + CMS G Codes + Measurement 7
Hierarchy 0f Activity Measurement 0 % Impairment 0 % 0 % Vigorous activities (run 5 miles) Managing finances 0 % 0% AM PAC OASIS 0 % FIM SF 36 0 % 0 % 100 % MDS Managing household Walk Slowly Trouble bending, stooping Need help to bathe Cannot maintain balance Move about with help FOTO Gen Ortho 100 % NOMS 0 % Berg Balance Scale 100 % 100 % Stand up with help Staying in bed/partly undressed 100 % 100 % Lying down most of the time 100 % 100 % 100 % Confined to room, bed Measures Converted 50000 100.0% 45000 90.0% 40000 80.0% 35000 70.0% 30000 25000 20000 15000 245,902 scores have been converted to date 117 Measurement instruments have been used 25 Measures account for 91.5% of conversions 60.0% 50.0% 40.0% 30.0% 10000 20.0% 5000 10.0% 0 0.0% 8
Most Frequently Used Measures (91.5%) 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 N=225,121 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Most Frequently Used Measures (90%) Montreal Cognitive Assessment Braden Scale Roland Morris Questionnaire Quebec Back Pain Disability Scale Upper Extremity Functional Scale Activities Specific Balance Confidence Scale Modified Elderly Mobility Scale Functional Gait Assessment OPTIMAL Functional Reach Test / Modified NOMS Swallowing Patient Specific Functional Scale Tinetti Performance Oriented Mobility Assessment Shoulder Pain and Disability Index Quick DASH Dynamic Gait Index Barthel Index Disabilities Arm, Shoulder, Hand Questionnaire Neck Disability Index Upper Extremity Functional Index Barthel Index Modified Oswestry Disability Index Timed Up and Go Berg Balance Scale Tinetti Gait & Balance Lower Extremity Functional Scale N= 110,504 0 5000 10000 15000 20000 25000 Adm AT DR MD/DO RN OT Other PT SLP 9
CBOR Calculator Use by Discipline 2666 17233 99047 OT 14.5% PT 83.3% SLP 2.2% N=118,946 SLP Use of Outcome Measures American Speech Language Hearing Association. (2013). ASHA SLP Health Care Survey 2013: Outcome Measures. Available from www.asha.org. 10
PT Instruments Used Top 25 measures (93.4%) recorded for discipline, N=99060 AMPAC: Basic Mobility Dizziness Handicapped Inventory Four Step Square Test Upper Extremity Functional Scale Roland Morris Questionnaire Barthel Index Modified Quebec Back Pain Disability Scale Functional Reach Test / Modified Functional Reach Test Activities Specific Balance Confidence Scale Modified Elderly Mobility Scale Patient Specific Functional Scale OPTIMAL Functional Gait Assessment Tinetti Performance Oriented Mobility Assessment Shoulder Pain and Disability Index Quick DASH Upper Extremity Functional Index Disabilities of the Arm, Shoulder, and Hand Questionnaire Dynamic Gait Index Neck Disability Index Oswestry Disability Index Timed Up and Go Berg Balance Scale Tinetti Gait & Balance Lower Extremity Functional Scale 0.4% 0.4% 0.5% 0.5% 0.6% 0.6% 0.6% 0.6% 0.7% 1.0% 1.0% 1.0% 1.1% 2.1% 2.2% 2.3% 2.4% 2.5% 3.1% 3.5% 6.0% 7.2% 14.6% 16.5% 21.9% 0% 5% 10% 15% 20% 25% OT Instruments Used (Top 25 measures (91.8%) recorded for discipline, N=12,609) AMPAC: Daily Activity Lower Limb Functional Index FOTO Elbow, Wrist, Hand Dynamic Gait Index Oswestry Disability Index Neck Disability Index Lower Extremity Functional Scale Upper Extremity Functional Scale Ashworth Scale /Modified Ashworth Scale Mini Mental State Examination Braden Scale Montreal Cognitive Assessment Box and Block Test Patient Specific Functional Scale Functional Independence Measure Shoulder Pain and Disability Index Timed Up and Go Functional Reach Test / Modified Functional Reach Test Tinetti Gait & Balance Berg Balance Scale Disabilities of the Arm, Shoulder, and Hand Questionnaire Quick DASH Upper Extremity Functional Index Barthel Index Barthel Index Modified 0.6% 0.6% 0.6% 0.7% 0.8% 0.9% 0.9% 0.9% 0.9% 1.2% 1.5% 1.6% 1.8% 1.9% 1.9% 2.1% 2.5% 2.7% 3.6% 4.5% 4.7% 5.0% 10.2% 17.4% 22.2% 0% 5% 10% 15% 20% 25% 11
SLP Instruments Used Top 25 (95.6%) of all measures recorded for discipline, N=2266 AMPAC: Applied Cognitive InpatientShort Form AMPAC: Basic Mobility Blessed Dementia Scale Facial Disability Index Activity Card Sort AMPAC: Applied Cognitive Generic Outpatient Executive Function Performance Test Lower Extremity Functional Scale Functional Reach Test / Modified Functional Reach Functional Independence Measure Barthel Index Modified AMPAC: Applied Cognitive Brief Cognitive Assessment Tool Timed Up and Go Rancho Levels of Cognitive Functioning Tinetti Gait & Balance NOMS Voice Berg Balance Scale NOMS Attention NOMS Motor Speech Mini Mental State Examination Montreal Cognitive Assessment NOMS Language NOMS Memory NOMS Swallowing 0.2% 0.2% 0.2% 0.3% 0.3% 0.4% 0.4% 0.4% 0.5% 0.5% 0.7% 0.8% 1.0% 1.1% 1.6% 1.8% 2.2% 2.4% 3.8% 3.8% 6.0% 7.6% 8.2% 10.5% 40.8% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Instruments Used Everyone Else Top 25 (95.8%) of all measures recorded for all others, N=6616 Penn Shoulder Scale Functional Gait Assessment Barthel Index (Original 0 20 scale) Mini Mental State Examination Functional Independence Measure Activity Card Sort AMPAC: Basic Mobility Dynamic Gait Index NOMS Swallowing Tinetti Performance Oriented Mobility Assessment Quick DASH Upper Extremity Functional Scale Action Research Arm Test OPTIMAL Barthel Index Modified Functional Reach Test / Modified Functional Reach Test Roland Morris Questionnaire Timed Up and Go Upper Extremity Functional Index Disabilities of the Arm, Shoulder, and Hand Questionnaire Neck Disability Index Tinetti Gait & Balance Berg Balance Scale Oswestry Disability Index Lower Extremity Functional Scale Other NUR MD/DO DR AT Admin 0 50 100 150 200 250 300 350 400 450 500 12
Professional Preferences Measure Use (%) per Discipline Total 60.0% 50.0% 48.3% SLP Measures 40.0% 30.0% 20.0% 53.8% PT Measures 44.1% OT Measures OT PT SLP 10.0% 0.0% Everyone Else 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% Adm N=392 AT N=267 MD/DO N=221 RN N=181 Other N=1233 15.0% 10.0% 5.0% 0.0% 13
Rehabilitation Problems Problems that rehabilitation professionals address involve interactions among multiple factors, including the individual s; Body structures and functions, Ability to perform activities and participate in society, Environmental barriers and facilitators present, and Personal factors unrelated to the health condition, but that may influence function and disability G Code Goals (reasons for receiving outpatient therapy) Top five clinical categories by therapy type Mobility: walking & Moving around Changing/Maintaining Body Position Carrying, Moving & Handling Objects Self care Other PT/OT Primary Other PT/OT Subsequent Swallowing Motor Speech Spoken Language Comprehension Spoken Language Expression Attention Memory Voice Other Speech Language Pathology Source: MedPAC analysis of 100 percent Medicare Part B therapy claims, 2009 14
Goals of Treatment AOTA suggests that the Other PT/OT code categories will not clarify the specific occupational therapy intervention goals. Use any code that fits your work with a patient, and be as specific as possible. http://www.aota.org/en/advocacy Policy/Federal Reg Affairs/Coding/G Code.aspx#sthash.ZbHzIcQC.dpuf Functional Measures and Therapy Goals Measure Abbr. Primary Assessment Use Lower Extremity Functional Scale LEFS ADLs, Balance, Coordination; Functional Mobility Tinetti Gait & Balance TGB Perception of balance and stability with ADLs Berg Balance Scale BBS Assess static balance and fall risk Timed Up and Go TUG Assess mobility, balance, walking ability Oswestry Disability Index ODI To assess symptoms and severity of LBP limiting function Barthel Index BI Assess quality of life, Function Limitation Barthel Index (Modified) BIM Assess quality of life, Function Limitation Neck Disability Index NDI Determine how neck pain affects a patient s daily life Disabilities of the Arm, Shoulder, Hand Questionnaire DASH Evaluate disorders of the upper limbs Upper Extremity Functional Index (UEFI) UEFI Determination of upper limb status and impairment Dynamic Gait Index DGI Ability to modify balance while walking Quick DASH QDASH Evaluate disorders of the upper limbs Shoulder Pain and Disability Index SPDI Measure current shoulder pain and disability Tinetti Performance Oriented Mobility Assessment TPOMA Measure balance Patient Specific Functional Scale PSFS Assess functional ability to complete specific activities Functional Gait Assessment FGA Assess postural stability during various walking tasks NOMS Swallowing NOMS S Assess swallowing ability Functional Reach Test / Modified Functional Reach Test FRT Assess a patient's stability Functional Independence Measure FIM Measure disability and assistance required for ADLs Modified Elderly Mobility Scale (MEMS) MEMS Test motor function levels OPTIMAL OPT Measure difficulty and self confidence in ADLs AM PAC: Basic Mobility AMPAC:BM Assess activity limitations Activities Specific Balance Confidence Scale ASB Measure ambulatory confidence Upper Extremity Functional Scale (UEFS) UEFS Assess functional ability to complete specific activities Four Step Square Test FSST Test of dynamic balance Mini Mental State Examination MMSE Detecting cognitive dysfunction Roland Morris Questionnaire RMQ Measure of back pain Box and Block Test BBT Assess unilateral gross manual dexterity Braden Scale (Pressure Ulcer) BRA Assess the risk of skin breakdown Montreal Cognitive Assessment (MoCA) MOCA Screening instrument for mild cognitive dysfunction Ashworth Scale /Modified Ashworth Scale ASHW Measure spasticity AMPAC: Daily Activity AMPAC:DA Assess activity limitations NOMS Memory NOMS M Assess Memory NOMS Language NOMS L Assess Language NOMS Motor Speech NOMS MS Assess Speech NOMS Attention NOMS A Assess Attention NOMS Voice NOMS V Assess Voice Rancho Levels of Cognitive Functioning RLCF Assess Cognitive Function 15
Measures Mapped to G Codes Rancho Levels of Cognitive Functioning NOMS Voice NOMS Attention NOMS Motor Speech NOMS Language NOMS Memory AMPAC: Daily Activity Ashworth Scale /Modified Ashworth Scale Montreal Cognitive Assessment (MoCA) Braden Scale (Pressure Ulcer) Box and Block Test Roland-Morris Questionnaire Mini-Mental State Examination Four Step Square Test Upper Extremity Functional Scale (UEFS) Activities-Specific Balance Confidence Scale AM-PAC: Basic Mobility OPTIMAL Modified Elderly Mobility Scale (MEMS) Functional Independence Measure Functional Reach Test / Modified Functional Reach Test NOMS Swallowing Functional Gait Assessment Patient Specific Functional Scale Tinetti Performance Oriented Mobility Assessment Shoulder Pain and Disability Index Quick DASH Dynamic Gait Index Upper Extremity Functional Index (UEFI) Disabilities of the Arm, Shoulder, and Hand Questionnaire Neck Disability Index Barthel Index (Modified) Barthel Index Oswestry Disability Index Timed Up and Go Berg Balance Scale Tinetti Gait & Balance Lower Extremity Functional Scale PT Measures Mapped to Therapy Goals 16
OT Measures Mapped to Therapy Goals SLP Measures Mapped to Therapy Goals 17
Average of Impairment Conversions All Measures All Patients CH 0 Admission Goal Discharge CI 10 CJ 20 30 CK 40 CK CK N 14,898 CK 50 N= 73,238 N= 88,236 60 CK Summary + G Code and severity modifier reporting is part of the CMS initiative to redefine Medicare beneficiary therapy needs and restructure payments anticipating a cost in excess of $700M over ten years. + Limited information has been summarized to provide the relationship of measures used to G Code reporting by outpatient therapists. + To date the value of these data have not been used for meaningful improvements in outpatient therapy or its cost reduction. + Clinical measurement tools to quantify functional impairment vary by professional discipline and their clinical focus in patient care. + Non standard calculation of functional impairment continues to impede accurate assessment of therapy value. + The alignment of therapy goals, standardized functional measurement and outcome valuation requires greater study and practice incentives to realize value based purchasing objectives. 18
For more information contact: Bob Habasevich bob.habasevich@mediware.com (480) 459 1619 Darlene D Altorio Jones darlene.d altorio jones@mediware.com (480) 291 4124 For more information visit: Mediware.com (888) MEDIWARE (633 4927) 19