• Functional Limitation Reporting Under Medicare

     
     
     
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    The Centers for Medicare and Medicaid Services (CMS) is mandated to collect, via claim forms, information on the beneficiary's functional status at the outset of the therapy episode of care, at specified points during treatment, and at the time of discharge. All practice settings that provide outpatient therapy services must provide this information. Nonpayable G-codes and severity modifiers are included on the forms to capture data on functional limitations, and the therapist's projected goal for functional status at the end of treatment must be reported on the first claim for services and at the end of the episode. More from APTA on the Medicare rule.

    CMS does not restrict or instruct therapists in the selection of functional outcome instruments. CMS recommends-but does not require-the use of 4 tests listed in the outpatient therapy Benefits Policy Manual (Chapter 15, Section 220.3C, "Documentation Requirements for Therapy Services"). CMS recognizes that there are a wide variety of outcome instruments available and that therapists may use more than 1 test in measuring a patient's functional limitation.

    Get the Tests & Measures You Need

    Access PTNow's list of functional outcome measures for high-volume conditions, including links to download tests whenever possible.

    Links to additional functional limitation reporting resources can be found further down this page.

    Clinical Judgment Is Critical

    The physical therapist's clinical judgment is critical in reporting functional limitation data, specifically as relates to selecting the appropriate severity modifier that reflects the score from a functional outcome measure or other performance measure. Read more.

    Caution is required when considering the use of calculators, as most calculators have no ability to consider the therapist's clinical judgments, other objective collected data, or patient-specific situations, and many calculators apply the tests in assigning severity when that is not a validated application of the test.


    Background: Supporting Clinicians

    To help clinicians meet requirements under the new rule, PTNow has prioritized adding functional outcome measures and enhancing the Clinical Tools area of the site so that search results can be sorted by functional limitation category:

    • Mobility: Walking & Moving Around
    • Changing & Maintaining Body Position
    • Carrying, Moving, & Handling Objects
    • Self-Care
    • Other PT/ OT Subsequent Functional Limitation


    Collaboration

    Clinical Tools Editor Paul Mintken, PT, PhD, OCS, Associate Editor Jane Sullivan, PT, DHS, MS, and APTA staff are collaborating with the following groups to identify and provide key outcome instruments that can be used to measure the severity of a patient's functional limitations:


    Identifying High-Volume Functional Outcome Measures

    In February, PTNow Co-chairs Judith Deutsch, PT, PhD, FAPTA, and Tara Jo Manal, PT, DPT, OCS, SCS; EDGE Chair Edee Field-Fote, PT, PhD; and APTA staff Heather Smith, PT, MPH, and Anita Bemis-Dougherty, PT, DPT, MAS, put out a call to sections and EDGE taskforces to "generate a list of the top 5 or 10 outcome measures for the top (highest-volume) conditions in their content areas."

    Emphasis was on selecting the best available measures based on the information currently available to these groups. PTNow is designed to be dynamic; measures and related information will be added, updated, and removed over time, as the various groups complete their work and as new evidence is published.

    In March and April, Section and EDGE workgroups submitted their functional outcome measure lists to PTNow.

    Initial Lists of Tests & Measures

    The names of more than 50 tests and measures were submitted to PTNow. Because of the July 1 deadline and the time needed to obtain licensing for the instruments and to develop related content, the tests and measures will be posted in stages, with some posted on PTNow before July 1, and others posted during the third and fourth quarters of 2013. The tests and measures selected for posting by July 1 are intended to serve only as primary examples for reporting the domain of interest. The selection of a specific test does not imply that APTA or EDGE endorses the test as the only test that may be used.

    To assist in staging, the PTNow team asked section and EDGE groups to help identify 1 or 2 "best" tests from their lists for each major content area. Field-Fote explains that "'best' doesn't mean 'perfect.' It means that a given measure, selected from a group of good measures, captures key elements of the construct that indicates change and has advantages, such as ease of standardization, low tech in terms of equipment needs, and efficient in terms of time to implement."

    Test & Measure Summaries

    Eventually, each test and measure will have a summary for each condition/population with which the test is used. Whenever possible, summaries will contain links to the actual test and how-to videos, instrument properties by condition/population, administration information, recommendations from professional workgroups when available, and relevant references. Summaries will be reviewed and updated on a regular basis. Using tools on each test summary page, users may recommend or comment on the tests and measures.


    Additional Resources

    List of Functional Mesures

    Tests and Measures Identified by Section, EDGE, and Other Groups

    More on Documentation Requirements

    Video: 2013 Reporting Patient Function to Medicare Webinar- 12/17/12

    FAQ: Functional Limitation Reporting: General Information

    FAQ: Documentation of the Functional Codes

    FAQ: G-Code Claims Submission

    Functional Limitation Reporting Categories and ICF

    Functional Limitation Reporting Categories and the International Classification of Functioning, Disability and Health (ICF)

    Case Scenarios

    Cerebrovascular Accident (CVA) (.pdf)

    Diabetic Foot Ulcer, Functional Limitations (.pdf)

    Diabetic Foot Ulcer, No Limitation (.pdf)

    Low Back Pain (LBP) (.pdf)

    Multiple Sclerosis, Establishing a Maintenance Plan/No Functional Change (.pdf)

    Neck Pain (.pdf)

    One Visit (.pdf)

    Reporting a Primary and Subsequent Limitation (.pdf)

    Skilled Nursing Facility, PT/OT (.pdf)

    Two Plans of Care, Same Facility (.pdf)

    Discussion Forum

    Functional Limitation Reporting Under Medicare Discussion Forum