Functional Outcomes Reporting for Patients with No Physical Disability
How to Determine Severity Code

The Problem. Functional outcomes reporting became mandatory in Medicare for all outpatient therapy claims on July 1, 2013. The problem is that there are currently few lymphedema measures or outcome tools to measure midline lymphedema (breast, torso, genital, head and neck), and few instruments suitable to measure early lymphedema before it becomes disabling when standard functional disability measures are appropriate.

Medical Treatment or Rehabilitation? Treatment of lymphedema falls into the Medicare definition of services covered that are reasonable and necessary for the treatment of illness or injury, and are not the same as rehabilitation services. For this reason different outcome measures may be more appropriate than the usual functional disability measures. We require instruments that measure severity of the illness or injury directly, rather than by the secondary disability caused by the illness.

What Does the Social Security Act Say? Section 1862(a)(1) of the Social Security Act (the Act) states that payment may be made under Medicare Part A or Part B only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member". In other words, an item or service must be reasonable and necessary for:
diagnosis of illness or injury; OR
treatment of illness or injury; OR
improving the functioning of a malformed body member.

The definition of covered "Medical and Other Health Services" is provided in Section 1861(s) of the Act, and I believe that there is a one-to-one correspondence between the covered medical objectives above and the provider of the provided service below:

"physician's services" §1861(s)(1); OR

"services and supplies ... furnished as an incident to a physician's professional service..." §1861(s)(2)(A); OR

"outpatient physical therapy services and outpatient occupational therapy services" §1861(s)(2)(D).

Separate Policy for Treatment and Rehabilitation? There is a qualitative difference between services provided for the "treatment of illness" and services provided for "... improving the functioning ...". This difference seems to have been lost when HCFA/CMS included all physical therapy (PT) and occupational therapy (OT) services under rehabilitation rules, therefore later subject to therapy caps and exceptions rules. [There was a brief period in the early 2000's when separate lymphedema treatment LCDs existed, separate from the outpatient therapy LCDs, but they have since been retired and the reason for their existence forgotten.]

Impact on Lymphedema Treatment. The blurring of differentiation between treatment of illness and improving functioning of a malformed body member appears to be leading to another blow to lymphedema treatment where therapy reimbursement will be shifting from a "services provided" to a "functional outcomes achieved" schema, and the outcome measures are, so far, all functional disability measures. None of the commonly used functional outcomes reporting instruments is sensitive enough to measure the severity of the underlying lymphedema before it becomes disabling, and when it is most easily treated.

Enter Functional Reporting. The Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 required the Centers for Medicare & Medicaid Services (CMS) to implement a claims-based data collection strategy for outpatient therapy services. CMS announced this collection strategy, known as "Functional Reporting", in the Calendar Year (CY) 2013 Physician Fee Schedule final rule (77 Federal Regulation 68958). Functional Reporting collects data on patient function during the therapy episode of care to understand beneficiary functional limitations and outcomes. Effective January 1, 2013, claims for outpatient therapy services were required to include non-payable G-codes and severity modifiers, which describe a beneficiary's functional limitation and severity level at specified intervals during the therapy episode of care.

How to Report When There Is No Functional Limitation. In its Guidelines for Selecting the G-codes to Report, CMS does recognize that not all therapy is targeted toward treating one of the four functional limitations (i.e. mobility,walking and moving around; changing body position; carrying, moving and handling objects; self care), and they have provided an "Other" category which is appropriate for lymphedema therapy:

• "The "Other PT/OT" functional G-codes are used when one of the four PT/OT categorical code sets does not describe the beneficiary's functional limitation, as follows:
• a beneficiary's functional limitation that is not defined by one of the four categories;
• a beneficiary whose therapy services are not intended to treat a functional limitation; or
• a beneficiary's functional limitation where an overall, composite, or other score from a functional assessment tool is used and does not clearly represent a functional limitation defined by one of the above four categorical PT/OT code sets." [CMS Provider Call, December 12, 2012]

• Specialized Tools and Therapist's Clinical Judgement. Further guidelines are given for selection of a severity modifier that are applicable to the documenting of lymphedema severity:
• "Use the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument, as appropriate.
• In cases where the therapist uses multiple measurement tools during the evaluative process to inform clinical decision making, clinical judgment is used to combine these results to determine a functional limitation percentage.
• Therapists can use their clinical judgment in the assignment of the appropriate modifier. Therapists will need to document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.
• Use the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat a functional limitation.
• In some cases for beneficiaries where improvement is expected to be limited, the same severity modifier may be used in reporting the current and goal status.
• In cases where the therapist does not expect improvement, such as for those individuals receiving maintenance therapy, the modifier used for projected goal status will be the same as the one for current status." [CMS Provider Call, December 12, 2012]

Measurement and Treatment Before There is Disability. Current research is leading to the conclusion that it is far better to detect lymphedema as early as possible and intervene to prevent or delay the swelling and destructive tissue changes, than to wait until there is appreciable measurable swelling or disability. Reference Stout's Prospective Surveillance Model which uses a 3% volume change threshold for intervention with compression sleeves, and Zimmermann, who uses MLD on all post-mastectomy patients from day 2 to prevent lymphedema. Sensitive measures of lymphedema, rather than secondary functional deficit, are needed if lymphedema diagnosis can be made and lymphedema therapy effectiveness measured.

Generalized Measurement Instruments. Most, if not all, therapy measures are based on the International Classification of Functioning, Disability and Health (ICF) model. Four instruments used by therapists over the years for evaluating function and disability (AM-PAC, FOTO, OPTIMAL and NOMS) have been suggested for use by CMS (Benefit Policy Manual CMS Publ. 100-02, Chapter 15, §220.3C Physical Therapy Evaluation/Re-Evaluation), however, they may not be sensitive to lymphedema severity in the absence of lymphedema-related functional deficit. Specific lymphedema instruments or lymphedema objective measurements may be more appropriate for measuring the effectiveness of therapy as a component of the treatment of the medical condition before disability.

The ALFP Survey. The following survey, a combined effort of Nicole Stout and Robert Weiss, was implemented as a "Survey Monkey" by the American Lymphedema Framework Project (ALFP) and used to inform therapists on lymphedema functional reporting. The specific items in the survey are listed below. Results of the survey have been embargoed pending publication.

Outcomes Measures.

• GENERAL MEASURES OF FUNCTION
• Activity Measure-Post Acute Care (AM-PAC)
• Focus On Therapeutic Outcomes (FOTO)
• OPTIMAL by Cedaron through the APTA
• National Outcomes Measurement System (NOMS) by the American Speech-Language-Hearing Association (ASHA)

• SPECIFIC MEASURES OF FUNCTION
• Disability of Arm, Shoulder and Hand (DASH and Quick DASH)
• Upper Extremity Functional Index (UEFI)
• Upper limb disability questionnaire (ULDQ)
• Dynamic Gait index
• Berg Balance score
• 6 minute walk test
• Timed up and go test
• Lower Limb Functional Index
• Vanderbilt Head and Neck symptom survey
• MD Anderson Symptom inventory- head and neck

• LYMPHEDEMA INSTRUMENTS
• LYMQOL (arm and leg)
• ULL-27 (UE only)
• Lymph ICF questionnaire (UE, LL)

• CLINICAL OBJECTIVE MEASURES
• Goniometric Range of Motion (ROM)
• Manual muscle testing
• Pain scale (0-10)
• Fatigue scale (0-10)

• LYMPHEDEMA OBJECTIVE MEASURES
• Circumferential limb volume measurement
• Limb volume calculated from circumferential measurement
• Limb volume from water displacement
• Optoelectronic Perometer
• Single frequency bioimpedance
• Multi frequency bioimpedance
• Skin Dielectric Constant
• Skin Thickness
• Skin Tone Mechanical
• Skin Tone Ultrasound

Informal Survey of Tools Being Used. An informal survey was made at my Reimbursement Issues networking table at the Lymphedema Seminar's Networking and Educational Seminar November 2, 2013 at Rancho Mirage, CA as to the measurement instruments used by lymphedema therapists reporting severity for their patient claims. The following measurement instruments were cited:

• PSFS (Patient-Specific Functional Scale)
• UEFI (Upper Extremity Functional Index)
• LEFI (Lower Extremity Functional Index)
• LEFS (Lower Extremity Functional Scale)
• AM-PAC (Activity Measure – Post Acute Care)
• Quick-DASH (Disabilities of the Arm, Shoulder and Hand)
• LYMQOL (Lymphedema Quality of Life Tool)
• Volume and girth
• Clinical judgement

New Lymphedema-Specific Measurement Instrument. There was interest in obtaining Dr. Jan Weiss' recently validated Lymphedema Life Impact Scale (LLIS). The Lymphedema Life Impact Scale (LLIS) is an 18-item patient questionnaire that measures the physical, functional, and psychosocial concerns pertinent to patients with lymphedema. This new validated instrument helps measure outcomes in patients with any extremity lymphedema. The Dysfunction Severity Calculator is a quick and easy Excel scoring instrument used in conjunction with the LLIS to automatically calculate percent impairment and assign an appropriate G-code as mandated by Medicare. Computer Requirements: Microsoft Excel, Adobe Reader. Allows use by one brick-and-mortar healthcare facility. Files are sent via email. These tools were created by Klose Training instructors Jan Weiss, PT, DHS, CLT-LANA, and Linda Hodgkins, MS, OTR/L, CLT-LANA.
Send your questions about the LLIS to jan@klosetraining.com.
Send your questions about the G-Code Calculator to lindah@klosetraining.com.

Conversion From Measurement Score to G-code Severity Modifier. One other useful resource which can be used to convert scores from a number of measurement instruments into CMS Medicare Part B severity G-codes is the Claims-Based Outcomes Reporting (CBOR) G-code Conversion Calculator by Mediware® found on the Mediware web page: http://www.mediware.com/rehabilitation/tools/item/g-code-conversion-calculator

USEFUL REFERENCES

CMS National Provider Call. Preparing for Therapy Required Functional Reporting Implementation in CY 2013. Pamela R. West, Presenter, December 12, 2012. http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/FunctionalReportingNPC.pdf

• Presented at the Lymphedema Seminars' Therapist Networking Seminar May 17, 2013 Cleveland, OH
• Nicole Stout "The American Lymphedema Framework Project: Aiming to Shape the Future of Lymphedema Care in the US" presented a comprehensive account of the rule that brought us functional outcomes measurement for therapy and the current implementation of the G-Codes for Medicare Part B billing.
• Maureen McBeth "Qualitative and Quantitative Measures of Lymphedema" covered objective measures of lymphedema in her presentation.
• DeCourcy Squire "Dealing with Head and Neck Lymphedema" dealt with the very specialized techniques of objective measurement of this non-extremity lymphedema.
• Jan Weiss "Development and Validation of the Lymphedema Life Impact Scale (LLIS)" presented a new subjective lymphedema outcome measure tool she is developing for upper and lower extremities.

MediServe Industry Resources Web Page http://www.mediserve.com/resources/
and G=code Converter http://www.mediware.com/rehabilitation/tools/item/g-code-conversion-calculator

clinicient Functional Limitation Reporting Blog
http://www.clinicient.com/category/functional-limitation-reporting/

APPENDIX A   Medicare Benefit Policy Manual CMS Pub. 100-02, Chapter 15 §220.4 - Functional Reporting

220.4 – Functional Reporting
(Rev. 165, Issued: 12-21-12, Effective: 01-01-13, Implementation: 01-07-13)

A. Selecting the G-codes to Use in Functional Reporting.

There are 42 functional G-codes, 14 sets of three codes each, for that can be used in identifying the functional limitation being reported. Six of the G-code sets are generally for PT and OT functional limitations and eight sets of G-codes are for SLP functional limitations. (For a list of these codes and descriptors, see Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6 F.)
Only one functional limitation shall be reported at a time. Consequently, the clinician must select the G-code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary reason for treatment. When the beneficiary has more than one functional limitation, the clinician may need to make a determination as to which functional limitation is primary. In these cases, the clinician may choose the functional limitation that is:

• Most clinically relevant to a successful outcome for the beneficiary;
• The one that would yield the quickest and/or greatest functional progress; or
• The one that is the greatest priority for the beneficiary.

In all cases, this primary functional limitation should reflect the predominant limitation that the furnished therapy services are intended to address.

For services typically reported as PT or OT, the clinician reports one of the "Other PT/OT" functional G-codes sets to report when one of the four PT/OT categorical code sets does not describe the beneficiary's functional limitation, as follows:

• a beneficiary's functional limitation that is not defined by one of the four categories;
• a beneficiary whose therapy services are not intended to treat a functional limitation; or
• a beneficiary's functional limitation where an overall, composite, or other score from a functional assessment tool is used and does not clearly represent a functional limitation defined by one of the above four categorical PT/OT code sets.

In addition, the subsequent "Other PT/OT" G-code set is only reported after the primary "Other PT/OT" G-code set has been reported for the beneficiary during the same episode of care.

For services typically reported as SLP services, the clinician uses the "Other SLP" functional G-code to report when the functional limitation being treated is not represented by one of the seven categorical SLP functional measures. In addition, the "Other SLP" G-code set is used to report where an overall, composite, or other score from an assessment tool that does not clearly represent a functional limitation defined by one of the seven categorical SLP measures.

B. Selecting the severity modifiers to use in functional reporting/documenting.

Each G-code requires one of the following severity modifiers. When the clinician reports any of the following a modifier is used to convey the severity of the functional limitation: current status, the goal status and the discharge status.

Modifier	Impairment Limitation Restriction
CH	0 percent impaired, limited or restricted
CI	At least 1 percent but less than 20 percent impaired, limited or restricted
CJ	At least 20 percent but less than 40 percent impaired, limited or restricted
CK	At least 40 percent but less than 60 percent impaired, limited or restricted
CL	At least 60 percent but less than 80 percent impaired, limited or restricted
CM	At least 80 percent but less than 100 percent impaired, limited or restricted
CN	100 percent impaired, limited or restricted

The severity modifier reflects the beneficiary's percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge. In selecting the severity modifier, the clinician:

• Uses the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument, as appropriate.
• Uses his/her clinical judgment to combine the results of multiple measurement tools used during the evaluative process to inform clinical decision making to determine a functional limitation percentage.
• Uses his/her clinical judgment in the assignment of the appropriate modifier.
• Uses the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation.

In some cases the modifier will be the same for current status and goal status. For example: where improvement is expected but it is not expected to be enough to move to another modifier, such as from 10 percent to 15 percent, the same severity modifier would be used in reporting the current and goal status. Also, when the clinician does not expect improvement, such as for individuals receiving maintenance therapy, the modifier used for projected goal status will be the same as the one for current status. In these cases, the discharge status may also include the same modifier.

Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.

C. Documentation of G-code and Severity Modifier Selection.

Documentation of the nonpayable G-codes and severity modifiers regarding functional limitations reported on claims must be included in the patient's medical record of therapy services for each required reporting. (See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6 for details about the functional reporting requirements on claims for therapy services, including PT, OT, and SLP services furnished in CORFs.)

Documentation of functional reporting in the medical record of therapy services must be completed by the clinician furnishing the therapy services:

• The qualified therapist furnishing the therapy services
• The physician/NPP personally furnishing the therapy services
• The qualified therapist furnishing services incident to the physician/NPP
• The physician/NPP for incident to services furnished by qualified personnel, who are not qualified therapists.

The qualified therapist furnishing the PT, OT, or SLP services in a CORF

APPENDIX B   LIST OF MEASUREMENT INSTRUMENTS AND REFERENCES

BIRS	Body Image and Relationship Scale
BISS	Body Image States Scale	Cash (2002)
CARES-SF	Cancer Rehabilitation Evaluation Syatem–Short Form	Schag (1991)
COOP	Dartmouth Primary Care Coop Information Project
DAS-24	Derriford Appearance Scale
DASH	Disabilities of the Arm, Shoulder and Hand	Gummesson (2003)
DASH/Quick DASH	Disability of Arm, Shoulder and Hand	Beaton (2001)
EORTC-QLQ-30	EORTC QoL Questionaire Core Questionaire V.3.0	Aaronson (1993)
EORTC-QLQ-BR23	EORTC QoL Questionnaire Breast Cancer Module	Sprangers (1996)
FACT-B	Functional Assessment of Cancer Therapy—Breast	Beaulac (2002)
FACT-B +4	FACT-B + 5 Lymphedema-Specific Questions
FACT-H&N	FACT Head and Neck	List (1996)
FLIC	Functional Living Index – Cancer	Schipper (1984)
FLQA-L	Freiburg Life Quality Assessment-Lymphedema	Augustin (2005)
GCLQ	Gynecologic Cancer Lymphedema Questionnaire	Carter, Barakat (2010)
HAD	Hospital Anxiety Depression Scale
ICF	ICF Core Set for Lymphedema	Viehoff (2012)
IDI-ILA part II	Instituto Dermopatico Dell'Immacolata (Italian LE Assn.)
IOC	Impact of Cancer Scale
LBCQ	Lymphoedema and Breast Cancer Questionnaire	Armer (2003)
LEL	Lower Extremity Lymphedema Index	Yamamoto (2011)
LLIS	Lymphedema Life Impact Scale	Weiss (2013)
LMFA-Y/-O	Lymphatic Malformation Function-Youth/-Observer	Patrick (2011)
Lymph-ICF	Lymphoedema Functioning, Disability and Health Questionnaire	Devoogdt (2011)
Lymph-ICF-LL	Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema	Devoogdt (2014)
LYMPH-Q		Massey, Pusic
LYMQOL	QoL measure for lymphedema of the limbs	Keeley (2004, 2010)
MDASI-HN	MD Anderson Symptom Inventory- Head & Neck Cancer	Cleeland (2000)
MSAS	Memorial Symptom Assessment Scale	Portenoy (1994)
NHP	Nottingham Health Profile
PGWB	Psychological General Well Being Index
QLQ-BCV	Quality of Life Breast Cancer Patient Version
RSCL	Rotterdam Symptom Checklist	De Haes (1990)
SF-36	Medical Outcomes Study 36-Item Short Form	Ware (1992)
telephone survey		Norman (2001)
UEFI	Upper Extremity Functional Index	Stratford (2001)
UEL	Upper Extremity Lymphedema Index	Yamamoto (2013)
ULL-27	Upper Limb Lymphedema	Launois (2000)
VHNSS	Vanderbilt Head and Neck Symptom Survey	Murphy (2010)
WCLS	Wesley Clinic Lymphedema Scale	Mirolo (1995)
WHOQOL-BREF	WHO QoL Assessment–Abbreviated Version

REFERENCE CITATIONS

• Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European organization for research and treatment of cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85:365–76.
• Armer JM, Radina ME, Porock D & Culbertson SD. Predicting breast cancer-related lymphedema using self-reported problems. Nurs Res. 2003;52:370-8.
• Beaulac SM, McNair LA, Scott TE, LaMorte WW and Kavanah MT. Lymphedema and Quality of Life in Survivors of Eraly-Stage Breast Cancer. Arch Surg. 2002;137:1253-7.
• Carter J, Raviv L, Appollo K, Baser R,Iasonos A & Barakat RR. A Pilot Study using the Gynecologic Cancer Lymphedema Questionnaire (GCLQ) as a clinical tool to identify lower extremity lymphedema in gynecologic cancer survivors. Gynecologic Oncology 2010;117:317-323.
• Cash TF, Fleming EC, Alindogan J et al. Beyond body image as a trait: The development and validation of the Body Image States Scale. Eating Disorders: J Treat Prevention. 2002;10(2):103-113.
• Cleeland CS, Mendoza TR, Wang XS, Chou C, Harle M, Morrissey M, & Engstrom MC. Assessing Symptom Distress in Cancer: The M.D. Anderson Symptom Inventory. Cancer 2000; 89:1634-1646.
• Devoogdt N, Van Kampen M, Geraerts I, et al. Lymphoedema Functioning, Disability and Health Questionnaire (Lymph-ICF): Reliability and Validity. Phys Ther. 2011;91:944-57.
• Devoogdt N, De Groef A, Hendricks A et al. Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL): Reliability and Validity. Phys Ther. 2014 published online before print.
• Gummesson C, Atroshi I and Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire. BMC Musculoskeletal Disorders 2003;4(11).
• Keeley V, Crooks S, Locke J, et al. A quality of life measure for limb lymphoedema. J Lymphoedema 2010;5(1)26-37.
• Launois R, Megnigbeto AC, Pocquet K, Alliot F. A specific quality of life scale in upper limb lymphoedema: the ULL-27 questionnaire. Lymphology. 2002;35(1–760):181–7.
• Massey MF & Pusic AL Developing the "LYMPH-Q"™ as a 360 Degree Clinical Outcomes Evaluation Tool,http://www.nilymph.com/ongoing-clinical-research-our-centers-excellence-care-lymphedema
• Mirolo BR, Bunce IH, Chapman M, et al. Psychosocial benefits of postmastectomy lymphedema therapy. Cancer Nurs. 1995;18(3):197–205.
• Mondry TE, Riffenburgh RH, Johnstone PAS. Prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer Journal 2004;10(1):42-8
• Murphy BA, Dietrich MS, Wells N, et al. Reliability and validityof the Vanderbilt head and neck symptom survey. Head Neck 2010;32(1):26-37.
• Norman SA, Miller LT, Erikson HB, et al. Development and Validation of a Telephone Questionaire to Characterize Lymphedema in Women Treated for Breast cancer. Physical Therapy 2001;81:1192-1205.
• Patrick D, Edwards T & Skalicky A. "Glass Half Full or Glass Half Empty": the Youth Quality of Life (YQOL) Generic and Condition-Specific Modules. PRO Newsletter 46, Fall 2011.
• Rosenthal DI, Mendoza TR, Chambers MS, Asper JA, Gning I, Kies MS, Weber RS, Lewin JS, Garden AS, Ang KK, Wang S, Cleeland CS. Measuring head and neck cancer symptom burden: The development and validation of the M. D. Anderson Symptom Inventory, head and neck module. Head Neck 29(10): 923-931, 2007
• Stratford P, Binkley J & Stratford D. Development and initial evaluation of the upper extremity functional index. Physiotherapy Canada 2001;53(4):259-67
• Weiss JM & Spray BJ. The effect of complete decongestive therapy on the quality of life of patients with peripheral lymphedema. Lymphology 2002;35:46-58.
• Wilburn O, Wilburn P, Rockson SG. A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema. BMC Cancer 2006; 6:84.
• Wilson RW, Hutson LM, VanStry D. Comparison of 2 quality-of-life questionnaires in women treated for breast cancer: the RAND 36-Item Health Survey and the Functional Living Index-Cancer. Physical Therapy 2005; 85(9):851-60.
• Yamamoto T, Matsuda N, Todokoro T et al. Lower extremity lymphedema index: A simple method for severity evaluation of lower extremity lymphedema. Ann Plas Surg. December 2011;67(6):637-40.
• Yamamoto T, Yamamoyto N, Hara H, et.al. Upper extremity lymphedema index: A simple method for severity evaluation of upper extremity lymphedema. Ann Plastic Surg. Jan 2013;70(1):47-9.

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