Although there’s no cure for osteoarthritis, it’s certainly possible for primary care physicians to not only help their patients manage symptoms, but also improve reimbursement for doing so.
The debilitating chronic condition affects more than 30 million adults in the United States, according to the CDC. Functional and pain assessments—something many physicians perform regularly—are critical because they help target interventions that ultimately improve patients’ quality of life.
These assessments can also boost payments under the Merit-based Incentive Payment System (MIPS), one of two participation tracks under the federal law that seek to reform Medicare payments while improving outcomes and reducing costs.
To satisfy MIPS criteria, physicians must report CPT code 1006F (indicating that they performed an assessment for function and pain) along with one of the following osteoarthritis diagnosis codes:
M16.-Osteoarthritis of hip
M17.-Osteoarthritis of knee
M18.-Osteoarthritis of first carpometacarpal joint
M19.-Other and unspecified osteoarthritis
Physicians aren’t required to use validated assessment instruments to get credit under MIPS. The only requirement is that the instrument assess pain and various functional elements including a patient’s ability to perform activities of daily living. For example, physicians can use a standardized scale or ask patients to complete a questionnaire such as Short Form-36 or American Academy of Orthopaedic Surgeons Hip and Knee Questionnaire. Acceptable pain assessments include the following:
- Visual Analog Scale
- Patient-Reported Outcomes Measurement Information System (PROMIS)
- Numeric Pain Rating System
Acceptable functional assessments include the following:
- General quality of life: Veterans RAND 12, PROMIS (PROMIS 10 or PROMIS Computerized Adaptive Test), or EuroQol-5D
- Foot and ankle: Foot and Ankle Ability Measure or Foot and Ankle Disability Index
- Knee (anterior cruciate ligament): International Knee Documentation Committee Subjective Knee Form or Marx Activity Rating Scale
- Knee (osteoarthritis): Knee Injury and Osteoarthritis Outcome Score (KOOS) or KOOS Jr.
- Hip (osteoarthritis): Hip Disability and Osteoarthritis Outcomes Survey (HOOS) or HOOS Jr.
- Shoulder: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Oxford Shoulder Score, or Single Assessment Numeric Evaluation
- Shoulder (instability): ASES or Western Ontario Shoulder Instability Index
- Elbow, wrist, and hand: Disabilities of the Arm, Shoulder, and Hand Score (DASH) or Quick-DASH
Assess for function & pain
Osteoarthritis functional and pain assessments help meet the overarching goal of MIPS to improve outcomes and reduce costs because these assessments help to identify patients who can benefit from early intervention, says James Daniels, MD, MPH, a primary care physician in Quincy, Ill. Daniels served on the American Academy of Orthopaedic Surgeons committee that helped develop the osteoarthritis MIPS measure.
“We’ve got an aging population. This means the volume of patients with osteoarthritis is rapidly expanding,” says Daniels, who is also professor of family medicine and orthopedic surgery at Southern Illinois School of Medicine in Carbondale, Ill. Osteoarthritis assessments can help physicians intervene and potentially improve long-term outcomes, reduce hospitalizations due to falls, and prevent expensive surgeries such as hip or knee replacements.
In many cases, functional and pain assessments paint a more accurate picture of a patient’s experience than a diagnostic image, says Fotios Koumpouras, MD, a rheumatologist and assistant professor of medicine at Yale University in New Haven, Conn. Koumpouras often sees cases in which an X-ray reveals minor disease, but the patient reports significant pain or loss of function that requires intervention.
However, physicians also need to be aware of the potential for inflated pain scores due to the presence of comorbid conditions, says Koumpouras. “We know by studies that individuals with depression, for example, will score worse on the pain assessments not necessarily due to their primary disease but because of comorbid conditions that affect their answers and perception of what’s going on,” he says. In these cases, physicians may need to address the underlying depression in order to improve osteoarthritis symptoms.
Still, the assessments are a good first step to get patients on the right course of treatment, says Nitin Damle, MD, an internist at South County Internal Medicine in Wakefield, R.I., and past president of the American College of Physicians. Half of his patients over age 50 have some degree of osteoarthritis. “[The assessments] give us a better idea of how to manage the osteoarthritis with anti-inflammatories, physical therapy,
weight reduction, stretching, tai chi, balance exercises, or a combination of all of these,” he says.
Aside from helping physicians meet the relevant MIPS measure, osteoarthritis functional and pain assessments can help justify to payers why patients may need physical therapy, says Daniels. The information also helps orthopedists to whom patients are referred. “The orthopedists don’t need to start from scratch, which probably saves a visit or two in terms of trying different methods,” he adds.
Finding the time for patients to complete these assessments—and then incorporating that information into the EHR—is a challenge, says Koumpouras. Some EHR vendors may be able to load the assessments so physicians can send them to patients via the portal for completion prior to their appointments.
Asking patients to come into the office in advance of their scheduled appointment time to complete the forms using the digital pen or completing the forms on paper and scanning them into the EHR may also be an option.
Carl Franzetti, DO, a primary care physician at Riverdale Family Practice in New York City, hopes to use his EHR kiosk to help perform the assessments. Between 70 and 80 percent of his patients over the age of 30 have some form of osteoarthritis. “Ideally, we want the patient to come in and go right to the kiosk to answer a series of questions that populates in the chart right away,” he adds. Patients already use the kiosk to answer questions related to activities of daily living, fall screenings, and depression screenings.
The goal is to have as much information as possible in the EHR prior to the physician stepping into the exam room so he or she can spend time recommending treatment rather than collecting information, says Daniels. “If you’ve done the history and physical—and you’ve got the imaging,” he says, “but you don’t have these other forms, you’re going to be making decisions without having the whole picture.”
Osteoarthritis documentation tips
Although there’s no cure for osteoarthritis, physicians can help patients manage this chronic condition to reduce overall costs. Doing so not only improves patients’ quality of life, but it can also boost physician payments under Medicare payment reform and in risk-adjusted payment models.
Anissa Calhoun, COC, CPC, CDEO, coding specialist in Boston, Mass., says physicians should document following details for osteoarthritis:
1. Type of osteoarthritis (i.e., polyosteoarthritis, primary, post-traumatic, or secondary).
2. Affected joints (i.e., hip, knee, first carpometacarpal joint, shoulder, elbow, wrist, hand, ankle, or foot).
3. Laterality (i.e., left, right, bilateral, or unilateral).
Generally speaking, payers are looking for specificity at all times, says Calhoun, adding that many physicians continue to document “osteoarthritis” without any additional information. “We had that grace period after ICD-10 went into effect when insurance companies were flexible with unspecified codes,” she says. “But now that time is over, and insurers are starting to require more information.”