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CHART: Selected Assessment Tools for OT Reporting of G-Codes and Modifiers (Medicare Part B)


8/12/2013

Occupational therapists providing outpatient therapy services to Medicare beneficiaries must report functional data in the form of G-Codes and modifiers to the Medicare program in order to receive reimbursement under Part B. Therapists are not required to use specific assessment tools in the selection of G-code modifiers, they are only required to rely on their clinical and professional judgment.

AOTA is providing this chart of selected assessment tools as a resource to occupational therapists, not as prescriptive guidance. Dowload a pdf version of the chart here.  See more at Functional Data Collection Requirements for Outpatient Therapy (AOTA, 2013) and Medicare Learning Network, ICN 908924 - Quick Reference Chart: Short & Long Descriptors for Therapy Functional Reporting G-codes (August 2013).

SELECTED ASSESSMENT TOOLS FOR OCCUPATIONAL THERAPY REPORTING OF OUTPATIENT FUNCTIONAL DATA (G-CODES AND MODIFIERS) TO THE MEDICARE PROGRAM

G-CODE CATEGORY

ASSESSMENT TOOLS*

NOTES

Mobility: Walking & Moving Around

Activities of Daily Living (ADL) Index

Interview and observation to determine ability with basic ADL and mobility tasks.

AM-PAC: Basic Mobility

The AM-PAC is an outcomes instrument that measures function in three domains: basic mobility, daily activities and applied cognitive. The AM-PAC™ can be used for quality improvement, outcomes monitoring, and research activities in inpatient and outpatient rehabilitation, home care, nursing homes and long-term acute care settings.

Modified Barthel Index

An ordinal scale used to measure performance in ADLs. It uses 10 variables describing ADLs and mobility.

Stroke Impact Scale

Measures stroke recovery in eight domains including strength, hand function, mobility, ADL, emotion, memory, communication and social participation.

Changing & Maintaining Body Position

Assessment of Motor and Process Skills (AMPS)

Requires training to administer. Proves an objective assessment of various motor and process skills.

Berg Balance Scale

Measures static and dynamic balance abilities using functional tasks commonly performed in everyday life.

Performance-Oriented Mobility Assessment (POMA)

Measures both static and dynamic balance using tasks testing balance and gait.

Timed Get Up and Go Test

Measures dynamic balance and mobility.

Carrying, Moving, & Handling Objects

Functional Reach Test

Quick, simple, single task dynamic test that defines functional reach as “the maximal distance one can reach forward beyond arm's length, while maintaining a fixed base of support in the standing position.” The test can be administered while the patient is standing (Functional Reach) or sitting (Modified Functional Reach).

Action Research Arm Test

Measures ADLs, coordination, dexterity, upper extremity function.

The Arm Motor Ability Test

Includes unilateral and bilateral tasks completion using basic ADL tasks. Best for higher functioning clients with active movement of wrist and hand.

Wolf Motor Function Test

Assesses the motor ability of individuals with moderate to severe upper extremity motor deficits. Includes reaching and functional activities requiring fine motor coordination.

Self-Care

Cleveland Scale of Activities of Daily Living

Evaluates basic ADL abilities in persons with dementia.

Modified Barthel ADL Index

Index of independence in ADLs created for hospital patients but can be used in sub-acute settings.

Patient-Specific Functional Scale

Patient determines functional ability with 5 activities (determined by therapist or patient) on a 10-point scale.

Activities of Daily Living Index

Interview and observation to determine ability with basic ADL and mobility tasks.

Functional Assessment Scale

Checklist-type rating scale of self-care function for institutionalized individuals.

Klein-Bell Activities of Daily Living Scale

Behavior rating scale of ADLs.

Melville-Nelson Self-Care Assessment

Observation-based rating scale of ADL abilities.

Performance Assessment of Self-Care Skills (PASS)

Observation-based performance rating of ADL function in the clinic or at home.

Executive Function Performance Test (EFPT) The EFPT was designed to evaluate an individual’s ability to perform IADL tasks necessary to live independently in the home; cooking, taking medication, making a phone call, and paying bills.

AM-PAC: Daily Activity

The AM-PAC is an outcomes instrument that measures function in three domains: basic mobility, daily activities and applied cognitive. The AM-PAC™ can be used for quality improvement, outcomes monitoring, and research activities in inpatient and outpatient rehabilitation, home care, nursing homes and long-term acute care settings.

Swallowing

The Mann Assessment of Swallowing Ability (MASA)

Designed for use in bedside evaluations of patients referred for swallowing function assessment.

Acute Stroke Dysphagia Screen

Easily administered and reliable tool that has sufficient sensitivity to detect both dysphagia and aspiration risk in acute stroke patients.

Victorian Dysphagia Screening Model ASSIST Tool

Completion of this screening tool is recommended in the presence of persisting acute stroke symptoms by personnel that have successfully completed approved training in dysphagia screening.

Swallowing Ability and Function Evaluation

Evaluates swallowing.

Attention

Test of Everyday Attention (TEA)

 

Measures 3 aspects of attention—selective attention, sustained attention, and attention switching—using everyday materials. This assessment is appropriate for use with individuals ranging from those with Alzheimer’s disease to young, “typical” clients.

Short Blessed Test

A short tool to assess orientation, memory, concentration.

Neurobehavioral Cognitive Status Screening Examination (COGNISTAT)

Brief screening of cognitive dysfunction. Provides profile scores for language constructions,  memory, calculations, reasoning, attention, level of consciousness, and orientation.

D2 Test of Attention

An easy to administer paper and pencil test that assesses the ability of the client to focus attention on certain aspects of letter and number combinations  over a period of time.

Memory

Contextual Memory Test

Helps assess memory capacity, strategy of use, and recall in adult clients with memory dysfunction.

Rivermead Behavioral Memory Test

Identifies everyday memory problems, monitors change over time, and assesses a wider range of ability.

AM-PAC: Applied Cognitive

The AM-PAC is an outcomes instrument that measures function in three domains: basic mobility, daily activities and applied cognitive. The AM-PAC™ can be used for quality improvement, outcomes monitoring, and research activities in inpatient and outpatient rehabilitation, home care, nursing homes and long-term acute care settings.

* Occupational therapists are not required by CMS to use a specific functional outcome assessment tool in the selection of a G-code or a modifier, and AOTA is not recommending the use of any one tool or instrument. When selecting a G-code, a therapist is to rely on his/her clinical and professional judgment. This chart is not designed to provide a comprehensive list of all clinical assessment tools appropriate for a G-code category; this chart simply provides a short list of selected tools that occupational therapists may find helpful in assessing patient function and selecting a modifier for each category. For a complete list, see: Asher, I. (2007), Occupational Therapy Assessment Tools: An Annotated Index. Bethesda, MD: AOTA Press, available here.