The communication of functional status (FSI) is a critical task for all health care stakeholders.  While instruments like the Outcome Assessment Information Set (OASIS), the Minimum Dataset (MDS), and the Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) address facets of functional status, they do not provide the flexibility necessary to support clinical decision-making or the establishment of patient-centered clinical treatment plans. Palmetto GBA, the Medicare Administrative Contractor serving Jurisdictions 1 and 11 has introduced the Going Beyond Diagnosis® (GBD) educational initiative to help address this unmet need.

Palmetto GBA is promoting the concepts contained in the International Classification of Functioning Disability and Health (ICF) as a framework for capturing and communicating the FSI necessary to support clinical decision-making and inform plans of treatment. Among the topics addressed by Palmetto GBA's GBD process is the documentation of evidence-based, fall evaluations and interventions. GBD utilizes sub-sets of the ICF taxonomy to help structure clinical documentation and match clinical interventions to the needs of individual patients.

Like the International Classification of Diseases (ICD), the ICF is part of the international family of classifications developed by the World Health Organization to communicate health status. Together the ICD and ICF taxonomies allow a comprehensive description of any individual's health status and can be used to develop and document clinical treatment plans. Although use of the ICF is not formally required by the Centers for Medicare and Medicaid Services (CMS), the data challenges facing health care providers today, especially those associated with the implementation of Electronic Health Records (EHRs), ICD-10-CM and Quality Assessment and Process Improvement (QAPI), would benefit from the GBD approach.

To learn more, visit the Palmetto GBA Going Beyond Diagnosis Blog at http://www.palmettogba.com/goingbeyonddiagnosisblog .