Crosswalking: The First Step in a Very Slippery Slope for Our Industry

Written by Heidi Jannenga on June 25, 2013

Ever since CMS announced the implementation of functional limitation reporting (FLR), people in our industry have been looking for ways to get by without complying. And because they couldn’t find a way to completely avoid FLR—and still get paid—they found a way to cheat. It’s what’s now known in the industry as crosswalking, or taking the results of an objective measurement tool and using a calculator to translate that number into an exact percentage of impairment (severity modifier).

So why is this such a big deal? Because aside from minimizing the importance of a critical reporting initiative, it’s stripping clinical judgment from the equation and basically telling the world that a monkey could do your job—or better yet, that a patient could go online, answer a few questions to complete an OMT, and self-diagnose. From there, it wouldn’t take much time to Google a few exercises, maybe a couple stretches. If that’s the case, who needs rehab therapists? What’s the point of fighting for autonomy, respect, and direct access if you’re going to tell the world that you don’t deserve it? Without specialized clinical judgment that comes from years of education and experience—and consideration of the context surrounding each individual case—there’s a huge piece missing from the patient’s story. That could be detrimental to the plan of care and ultimately the therapy experience.

We feel strongly that this could be the beginning of a very steep decline for our industry as a whole—if we succumb to this first step in a very slippery slope, that is. It also deeply saddens us to see some of our competitors falling over themselves to create these crosswalking calculators to “help” therapists get by. It’s not helping anyone. And you as therapists don’t need to just “get by.” You’ve fought for what you have. You’ve battled legislation trying to restrict your right to practice; you’ve kept your doors open despite the POPT moving in around the corner; and you’re a damn good therapist. So, prove it.

Show Medicare—and the world—that you’ve got this and you’re going to do it the right way—with honesty, integrity, and professionalism. Don’t fall victim to cheating, to crosswalking. If not for yourself, then for your patients. They need you—not a calculator, not Google, not software that plugs and chugs everything (thinks!) for you. You are, after all, the expert. Aren’t you?

Posted Under: Functional Limitation Reporting
About Heidi Jannenga

Heidi was a scholarship athlete at the University of California, Davis. Following a knee injury and subsequent successful rehabilitation, Heidi developed a passion for physical therapy. She started her 16-year physical therapy career after graduating with her Masters from the Institute of Physical Therapy in St. Augustine, Florida. In 2008, Heidi and her husband Brad launched WebPT, the leading web-based Electronic Medical Record (EMR) and comprehensive practice management service for physical therapists. As the company’s COO, Heidi is responsible for product development/management, billing services, and customer support. She resides in Phoenix with Brad and their daughter.


7 replies to “Crosswalking: The First Step in a Very Slippery Slope for Our Industry

  1. Bryce

    The following is from the CMS FAQs on their website…regarding crosswalking:

    You will need to convert the score from the “wellness” scale, a scale in which 100 means no disability, to the CMS “disability” scale in which zero (0) means no disability. For example, if a beneficiary scored 60 (out of 100) where 100% means no disability), this score converts to a 40 on a scale where 100% means totally disabled. To make this conversion, the wellness score of 60 is subtracted from 100 to yield a score of 40 on the disability scale.

  2. Tracy

    It’s not about “getting by”. Rather, we should use a combination of smart tools and good clinical judgement skills to foster great time management and exceptional patient care. Many of the WebPT features are set up to do just that.

    Am I on a slippery slope if I locate a great picture of an exercise via Google and then provide that to the patient WITH a full in-person demo of the exercise and patient demo with appropriate modifications for safety and efficacy? I’m using my skill and clinical judgement. That just saved me a lot of time and is actually providing value. I didn’t have to take the time to draw a terrible stick figure (when the picture is not available on a rehab website). I also utilized clinical judgement in ascertaining what exercise would be most appropriate.

    The therapists can still use discretion. We can still use clinical judgement but have a reference. Therapists still have the professional responsibility to decide: IF they are going to use the calculations, if it is a valid test for measuring disability; and they can always do their own calculations as a cross-reference. Let’s work together to create a great, supportive environment rather than suggesting therapists are cheating. We have a great profession and many therapists are doing a fantastic job, in light of all of the changes.

  3. Charlotte Bohnett

    Hi Tracy,

    Thanks for reaching out! To clarify, the slippery slope we mention is using an outcome measurement tool to determine a severity modifier without applying clinical judgment. That is, using a tool—and a tool alone—to replace the expertise of a therapist. To your point about picking our battles, we feel this actually directly aligns with the fight for autonomy and direct access—and as such, it’s extremely important. We’d argue that taking clinical judgment out of the equation doesn’t demonstrate the best we can offer in terms of therapy and is detrimental to our fight for respect as medical professionals.

    That being said, of course using reference tools to aid you in your assessment is perfectly fine—they just shouldn’t replace you as the expert. And you’re absolutely right: Therapists are doing a fantastic job. We certainly did not mean for this article to be anything other than a call to keep doing a fantastic job.

    Again, we really appreciate your feedback. It’s through such comments that we learn and can continue to produce educational and discussion-generating content.

    Thank you

  4. Tim Richardson

    I completely agree with Heidi’s passion but I think she’s too critical of calculators – among WebPT’s finest innovation’s are their time-saving G-code and Severity Modifier calculators built right into their EMR.

    Tomorrow’s therapists will come to regard the current crop of calculators the way we currently regard goniometers, tape measures and force dynamometers – just one more clinical tool for collecting data.

    Thank you,

    Tim Richardson, PT

  5. Tim Richardson

    “Cheating” is too strong a word to describe crosswalking. “Simplifying” is more accurate.

    The APTA provides a nice example of crosswalking the OPTIMAL scale to the ICF Activity Limitations and Participation Restrictions. I don’t think the APTA crosswalked the OPTIMAL to help physical therapists “cheat”.

    Incidently, the OPTIMAL is the only scale that uses exclusively the ICF Activity Limitations and Participation Restrictions – most other scales include some combination of these ICF domains with impairment-level variables.

    Here is the link to the APTA site (no membership required for this information):
    http://www.apta.org/uploadedFiles/APTAorg/Practice_and_Patient_Care/Practice_Administration/Documentation_and_Records/Documentation/OPTIMAL/Optimal_MappingtoICFCodes.pdf

    Again, I appreciate Heidi’s passion. Keep up the good work.

    Tim Richardson, PT

    1. Post Author Heidi Jannenga

      Hi Tim,

      Thanks for your comments. I want to emphasize that I completely agree with you on the importance of clinical tools developed through evidence-based practice. However, when I talk about crosswalking, I mean the practice of a simple plug-and-chug: you complete an OMT and a calculator takes your score and arbitrarily links it to a severity modifier. Granted, there are some OMTs—such as the Oswestry—that have indexes that allow for crosswalking scales backed by extensive clinical research. The calculators associated with most of these tools today, however, lack a foundation in thorough and consistent research. Some of the OMTs themselves even lack thorough enough research. Thus, they are not—in my opinion—accurate enough to use on their own, without clinical judgment.

      I apologize if “cheating” comes across as too strong, but in my opinion, calculating a severity modifier based solely on the results of an outcome measurement tool without using clinical judgment is far more than “simplifying.” To me, it’s the equivalent of using CliffsNotes to write a book report, and if I were the one teaching that Lit class, I’d call such a shortcut cheating.

      Lastly, regarding your comment about “WebPT’s finest innovation’s are their time-saving G-code and Severity Modifier calculators built right into their EMR,” I greatly appreciate the high-praise. However, this praise is a bit misplaced. Yes, we consider our functional limitation reporting feature quite innovative, and it’s a huge time-saver for our Members, but we do not offer any crosswalking calculators. We score your OMT. However, we do not crosswalk that score to directly match a severity modifier. We guide the selection of G-codes and severity modifiers, but ultimately it’s up to the therapist’s educated discretion.

      Thanks again for your feedback,
      Heidi Jannenga

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