Reimbursement for G-codes?

We're using G-codes as a stepping-stone to an outcomes-based reimbursement system, aren't we?" asked my client today. Jami is a nurse running a occupational theapy hand clinic. Jami is preparing her office for mandatory G-code reporting on July 1st, 2013.

"No", I replied. "We're just reporting our compliance.  We're not measuring function."

"Well, we showing we're getting the patient better, aren't we?", replied Jani.

"No, not really", I replied. I paused in the conversation, not sure how I could quickly explain the statistical concepts needed to understand why Functional Reporting using G-codes and Severity Modifiers could not lead physical therapists to true outcomes reporting.

"What a bust for FOTO", I thought.  Focus on Therapeutic Outcomes had the Cadillac risk-adjusted outcomes measurement system for therapy services in the world and the US government took a pass on them and chose G-codes and Severity Modifiers instead.

Of course, FOTO costs $250 for set-up and $25 per month per therapist.  And, they own the outcomes marketplace.  There is essentially no competition.  I could just imagine the hue and cry if the government granted a de facto monopoly to FOTO and mandated that every therapist measure patient outcomes using a risk-adjusted measurement scale, like FOTO.

"We know how to measure outcomes!", Jami said, eagerly. "We're using the DASH already!"

"I use the DASH, too", I explained.  "And, that's what Medicare wants.  But, a discharge score on the DASH that is, say. 20-points better than the initial score can't be used to compare your clinic to mine."

There are four levels of measurement (adapted from Jewell):

Level of Measurement	Example
Nominal	apple, orange, pear
Ordinal	happy/sad OR hot/warm/cold OR MMT grades
Interval	temperature, height, weight
Ratio	blood pressure, speed and distance

There is not a fixed interval between values such as "happy" or "sad" or, for that matter, the rank ordered scales of the OPTIMAL, the DASH or any of the other paper questionnaires.

These rank orderings are not numbers but are indicators for modifying words. The OPTIMAL uses words for values such as 2 = "little difficulty".

The lack of a fixed interval between these values means that mathmatical functions cannot be performed on them. The difference between a "1" and a "2" is not the same as the difference between a "2" and a "3". We can't add, subtract, multiply or divide OPTIMAL, DASH or any of the other self-report scales becuse they lack intervals.

The interval level of measurement has a fixed interval between each number which allows addition and subtraction. A 10-point change in temperature from ninety degrees to eighty degrees is the same ten point change from fifty to forty degrees.

The ratio level of measurement has a known zero point which indicates the absence of the chacteristic being measured. Zero miles per hour means the car is standing still. Ratio data can be manipulated like interval data with addition and subtraction. Also, ratio data can be manipulated with multiplication and division.

All of these techniques are being used to convert self-report scale data from raw scores to the new Medicare Severity Modifier scale.

That is probably fine for simple reporting to prove to Medicare that physical therapists can report functional scores.

But, when Medicare starts paying one therapist more money for better outcomes based on functional data they had better create something better than G-codes and the Severity Modifiers.

This is Only a Test...

Functional Reporting for Medicare in 2013 is only a test.

If Functional Reporting were true outcomes reporting physical therapists would need to use risk-adjusted outcomes measures, not paper questionnaires.

Instead of true outcomes reporting, physical therapists are only being assessed on our ability to report patient functional status via the claims system.

The Centers for Medicare and Medicaid (CMS) states in Transmittal 165 that this new system is designed to assess the ability of physical therapists to report patient functional status via claims forms, like the CMS 1500.

A trusted source at the APTA states that Medicare just wants physical therapists to show that we are using functional status measures and that we can predict change.

However, the change scores are not valid indicators of change.  And, the functional status scores can't be used as valid indicators of patient function. They can't even be used to compare my outcomes to your outcomes.

According to Jewell (p.154), "These (ordinal scores) are not measured with numbers, but are indicated with modifying words.  The absence of a known distance between each level of these scales means that mathematical functions cannot be performed directly with the measure."

Ordinal data, such as reported on the OPTIMAL scale, Oswestry, LEFS, SPADI, ABC, DHI, Berg etc. can't be used to do addition and subtraction, multiplication or division.

However, the new Medicare Severity Scale require physical therapists to convert the raw scale scores to percentage categories corresponding to modifiers that can be appended to the CMS 1500 paper or electronic claim form.

Medicare Severity Scale for G-code Modifiers

When this important detail was pointed out to me, I was initially surprised and disappointed.  I originally saw Functional Reporting as a stepping stone to true outcomes reporting.

Not the case, says my trusted source.  "Don't get caught up in the math," he said, "The numbers aren't important", he implied.

"Functional Reporting is here to stay but you're not measuring true outcomes and you shouldn't expect this data to be used to improve the reimbursement situation for physical therapists."

Like I said, this is only a test.

A Resource for Functional Reporting in 2013 for Physical Therapists

Are you concerned about the new Medicare mandates for Functional Reporting for therapy services in 2013? Are you and your staff fully equipped to manage the change?  Do you know which are the best reporting templates?

I've written a new book for physical therapist managers to implement Functional Reporting based on 8 years of experience with self-report measures in my private practice.

This book is for therapists new to functional reporting as well as for therapists who need to gain that extra edge to remain competitive.

I've written this book, pictured in the upper left, for physical therapy managers to implement self-report questionnaires into their clinical workflow. The book was published January 7th, 2012 and it has so far sold well.

I started implementing functional testing systematically in 2005.  I had the help of my fellow PTs, physical therapist assistants, administrators, and various support staff.  We also started the Physician Quality Reporting Initiative (PQRI) in July 2007, the first year physical therapists were eligible to report.

Chapter One discusses the implementation process, Chapter Two discusses therapist-scored performance measures like the Berg score. The bulk of the book (pp. 73 - 131) describes in detail the self-report tests physical therapists use. I describe 20 self-report tests.

Smart managers will choose the top two or three tests for their high-volume caseloads. Click the link in the upper left to buy the book from the publisher's website at a substantial discount from Amazon. Please e-mail me with any questions you might have.