As I indicated in some prior posts linked at the bottom of this post, we have the attention of Medicare.
Under the Microscope
To review, the Medicare Payment Advisory Commission (MedPAC) has made it clear that therapy services are going to be under close scrutiny. Using physicians as gatekeepers and using an annual cap with an automatic exceptions process has not changed therapy utilization in any meaningful way. Put more simply, from MedPAC’s perspective, Medicare doesn’t know what benefit patients are receiving, while costs for therapy services have continued to increase by 10% or more per year.
Back to the Drawing Board
So, CMS has devised a system to collect information that will be required on Medicare claims assessing the functional limitations and changes in functional limitations for therapy patients. This system to collect functional limitations will begin implementation in January of 2013.
The idea of collecting information on functional limitations and improvements on claims is good in theory, but, as usual, the devil is in the details:
- All assessment tools are not created equal. Changes in the scores or ratings of these tools will not always lend themselves to readily translate to the Severity/Complexity Modifiers. For example, the LEFS and DASH are both widely accepted assessment tools and they don’t even try to assign any sort of functional level based on score. LEFS and DASH scores only indicate whether or not there is a significant change.
- What does a percentage of improvement mean on a given assessment tool? An improvement of 10% on a selected questionnaire does not mean the patient has 10% better function.
- Similarly, score changes on the hundreds of acceptable assessment tools are not always linear… a change from say 10 to 20 on a given instrument may indicate more or less overall improvement than a change from 21 to 30.
- The severity/complexity modifiers have a low degree of specificity. There is a big difference between “at least 20%” and “less than 40%” impaired. A patient improving from 21% to 39% impaired would appear to have made no improvement at all.
- On one hand, it looks like CMS recognizes these shortcomings, since therapists will be able to use their professional judgment in the selection of the appropriate modifier. So, which is it? Does a therapist use the results from the assessment tool or not?
My colleague, Keddrick Stuart, will review the process for functional limitation reporting and how Clinicient will support this requirement in a future post.
Prior Posts: