G-Codes Versus ASHA NOMS
by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
First of all, cheers to our G-Codes!
It has been many years since the Centers for Medicare & Medicaid Services (CMS) introduced “Functional Limitation Reporting” and G-Codes into our lives!
The Dysphagia Rating Question:
As a dysphagia clinician,
are you using the 7-point scales from ASHA’s National Outcomes Measurement System (NOMS) to assist with your reporting of G-Codes?
These now familiar 7-point scales are actually part of ASHA’s National Outcome Measurement System (NOMS) and only available to clinicians contributing data to ASHA’s NOMS registry. The NOMS Functional Communication Measures (FCMs), which are 7-point scales encompassing 15 cognitive, speech, language, voice and swallowing categories are copyrighted for exclusive use in NOMS data collection. Therefore, I was asked by ASHA to take the NOMS measures and ASHA’s FCMs off this website, as their use requires participation in NOMS.
“There has been a lot of confusion between NOMS reporting and claims-based reporting of G-Codes,” stated Tobi Frymark, ASHA’s Associate Director of the National Center for Evidence-Based Practice in Communication Disorders. “NOMS is ASHA’s online data collection and reporting tool designed to track the outcomes of all patients receiving speech-language pathology treatment across the healthcare continuum,” per Frymark. Individuals, organizations, and/or healthcare systems register to participate in NOMS and execute a community subscription agreement with ASHA. In exchange for submission of data to ASHA’s national registry, clinicians “have access to the NOMS reporting tool and its proprietary scales (FCMs), as well as the comparative data reports benchmarking the outcomes of patients to the national average,” reminded Frymark.
According Frymark and ASHA, you should NOT be using these scales, UNLESS you or your healthcare organization has entered a contractual agreement with ASHA to have permission to utilize NOMS. In other words, if you are not a registered ASHA NOMS user or affiliated with an active NOMS-registered facility, you cannot use the 7-point FCMs for your G-Code reporting.
See the latest news on ASHA.org (updated link as of 2020).
Here are excerpts from their old version of Frequently Asked Questions:
“How is NOMS related to the outcome measurement requirements using G-Codes?”
Answer: “The Centers for Medicare and Medicaid Services (CMS) requirement that all SLPs treating Medicare B patients submit outcomes data with the claim for the service is not the same as participating in NOMS data collection. CMS adopted a series of outcome measures known as “G-codes” with accompanying severity/complexity modifiers for claims-based reporting. The CMS measures are based on the NOMS scales—ASHA’s Functional Communication Measures (FCMs)—a series of seven-point rating scales ranging from a least functional (Level 1) to a most functional (Level 7). As such, NOMS and its FCMs can easily be used to report and track outcomes of Medicare patients.”
This introduction makes it sound like the FCMs can be “easily” used. However, here is another question answered:
“Can I use the NOMS scales (ASHA’s Functional Communication Measures) or complete the training without participating in data collection?”
Answer: “No. The NOMS Adult data collection tool, its Functional Communication Measures (FCMs) and the training, are for data collection sites only. The FCMs are copyrighted for exclusive use in NOMS data collection.”
To be honest, I was surprised too!
Many clinicians are using these 7-point scales for G-Code reporting on a daily basis and may not know if their facility has a contractual agreement in order to use ASHA NOMS.
The Dysphagia Rating Dilemma:
The ASHA NOMS so naturally correspond to the G-code requirements from the Centers for Medicare & Medicaid Services (CMS), because the CMS measures were based on the NOMS scales! However, CMS does not mandate the usage of specifically the ASHA NOMS to be in compliance with Medicare’s G-code reporting. CMS only requires that the severity modifier be chosen, but at this time, does not require what measure you use to determine your modifier.
Frymark provided a list of other outcome measures that were compiled by members of ASHA. It is not a complete list, and it is NOT endorsed by ASHA. Please click here for this partial list of other Functional Outcome Measures. Unfortunately, this list is severely lacking in scales appropriate for dysphagia.
For examples:
The 18 motoric and cognitive categories of the Functional Independence Measure (FIM) include “Eating” but NOT “Swallowing.” See Kohler, et al., 2009 for one article addressing the problems with inter-rater reliability of these general scales that range from completely independent to completely dependent.
The EAT-10 and SWAL-QOL are on the list, but these are not a 7-point rating scales. The EAT-10 is an excellent self-screening tool that can identify how a swallowing deficit can affect function and quality of life. The 10 questions can be given to the patient on the initial assessment, during treatment and at the end of treatment to track the patient’s response to treatment. (Please also see this page with links to other quality of life measures).
The Functional Oral Intake Scale (FOIS) is the only dysphagia-related 7-point scale that I see on this list. The FOIS only addresses how the patient is receiving nutrition (i.e., dependence on tube feeding at one end and full oral intake without restrictions at the other end of the scale). The FOIS does not rate the physiological deficits or track improvements in actual swallowing function over time. However, the same can be said about the ASHA NOMS’ FCMs for swallowing. In general, rating based on a patient’s non-oral versus oral intake can be fraught with problems. The further unfortunate fact about G-Code reporting, is that we often have to give the patient’s “current status” rating when we have only completed a bedside swallowing evaluation (see prior blog).
This is pure speculation on severity — unless,
as a super-hero clinician, you have developed x-ray vision.
The Dysphagia Severity Rating Scale was not mentioned at all in the above list of Functional Outcome Measures. The Dysphagia Severity Rating Scale can be used after an instrumental exam, and at least it mentions the amount of aspiration and if the cough reflex is non-productive or absent.
Click here for a pdf of dysphagia-related 7-Point scales for G-Codes (not related to ASHA NOMS). This pdf includes the Dysphagia Severity Rating Scale and the FOIS, with references included.
What Can I Do Now?
1. Please share other ideas for valid and reliable 7-point scales.
2. Learn about the benefits of becoming an ASHA NOMS user so that you have full access to:
a. NOMS reporting tools and its FCMs (the 15 7-point proprietary scales),
b. Comparative data reports benchmarking the outcomes of your patients against the national data, and
c. ASHA’s national registry – by contributing data you will assist ASHA with advocacy efforts.
It is a FREE member benefit to be an ASHA NOMS user, and it is FREE for your facility to register. Click here for more information about NOMS and the benefits of participation in ASHA’s data collection.
“The aggregated national data is important to ASHA ,” shared Frymark, “It is used to advocate on behalf our members to show the value of SLP services to multiple audiences.”
For example, ASHA can fight for the need for more therapy for a stroke patient, showing national data on the length of therapy that is required to make significant and meaningful progress in aphasia therapy or dysphagia therapy. ASHA has data that shows a typical stroke patient will be less likely to make progress in swallowing if he/she has <2 hours of therapy, but the majority of stroke patients (77%) will make some progress in FCM levels if given over 4 hours of therapy (per the “NOMS: Adults in Healthcare, Acute Hospital, National Data Report 2007-2011”).
As a registered user, you receive national benchmarks to compare your patient and your program against national averages. You can ask: Are my patients making the expected amount of progress? How many sessions should be needed to make that amount of progress?
3. Contact ASHA for more information:
a. For more information on becoming a registered ASHA NOMS user, to see if your facility is registered, and/or to assist your facility in the registration process, contact:
Tobi Frymark,
ASHA’s Associate Director of the National Center for Evidence-based Practice in Communication Disorders
b. For more information about Medicare, contact:
Lisa Satterfield,
ASHA’s Director of Healthcare Advocacy