Author Response

I appreciate Escorpizo's comments on my editorial on the Medicare mandate for claims-based functional data collection.¹ Although the editorial did not mention the International Classification of Functioning, Disability and Health (ICF) directly, Escorpizo is absolutely on the mark in drawing associations between the mandated functional status reporting system and the ICF. The general categories of functional impairment (G codes) that therapists can use to meet Centers for Medicare and Medicaid Services (CMS) requirements are certainly based on the ICF taxonomy and represent aspects of functioning that are addressed in rehabilitation treatment. That said, to satisfy the CMS mandate, therapists must report on and track only a single primary functional impairment on the claims form. Although therapists could—if they so desired—track all categories of functional impairment in the physical therapy record, CMS does not require them to do so, nor does CMS require that therapists assess any specific domains of functioning that may be important for patients with specific types of conditions.

Therefore, the data that will be entered on Medicare claims forms will be extremely limited and will not provide a comprehensive picture of the variety of limitations addressed by therapists. In my view, the CMS minimal requirement may introduce some ICF terminology to practitioners, but it is a far cry from the vision of “systematically implementing the ICF” in clinical practice. Escorpizo refers us to earlier articles^2,3 that remind us that the implementation of the ICF in practice would need to be far more comprehensive and complex than simply fulfilling mandatory CMS functional reporting requirements. Indeed, the ICF offers a comprehensive theoretical framework and standardized language for describing function and for targeting treatment. The ICF framework is already being used throughout the world to inform minimum standardized data collection efforts. The ICF framework could be embraced by CMS and used to identify additional standardized data elements based on ICF core sets for specific patient subgroups.^4–9

If such a requirement were forthcoming, the additional information would help to better characterize patients receiving rehabilitation and to perform risk-adjustment of outcomes when evaluating quality or developing payment reform strategies. However, I do not believe that a more complete adoption of the ICF framework would resolve issues related to measurement of severity of functional impairment as currently required by CMS. In my view, CMS should require a limited set of validated, standardized outcome measures that would be used by all providers, and providers should report on actual measurement scores (and not severity modifiers). The choice of the most appropriate outcome measures and the method for scoring measures needs to be based on accumulated evidence in the scientific literature. At this time, there is little empirical evidence to support the use of the ICF qualifiers as reliable or valid outcome measures,¹⁰ and no evidence to suggest that the use of severity modifiers would be reliable, valid, or sensitive to change.

I thank Escorpizo for heightening our awareness that the Medicare-mandated functional status reporting requirement can be used as an opportunity to further the implementation of the ICF in the United States.

• © 2013 American Physical Therapy Association