Background: Low back pain is prevalent worldwide and is a disabling factor of almost epidemic proportions. One in four United States adults has experienced at least one daylong episode of low back pain. Low back pain is also one of the most common presenting complaints in the primary care outpatient clinic. Literature has shown that 15-40% of low back pain may be attributed to a facet-mediated cause. In 2008 the Department of Health and Human Services’ Office of the Inspector General released findings showing that the request for treatment of chronic low back pain from facet injections alone submitted to Medicare reached a staggering $307 million in 2006. An estimated 63% of those treated did not meet qualifications as defined by Medicare for the treatments, resulting in $96 million in improper payments to providers. Foreground: The new Local Coverage Determination (LCD) requires documentation of the use of a specific pain and disability measuring tool. The purpose of the capstone project was to implement the patient-rated Oswestry Low Back Pain Disability Index (ODI) at a local pain relief institute. The ODI descibes adult patients’ level of perceived disability regarding their facet-generated back pain. The use of the ODI can assist the providers of the institute in complying with the Medicare LCD. Medicare reimbursement denials reached $400,000 in 2009 at the institute, secondary to the changes instituted by the Medicare LCD. The long term objective of the project was to help maximize Medicare reimbursements. The medical director and his group were concerned about the delay, if not total lack of care due to a fear of not being reimbursed by Medicare. Objectives: The goal of the capstone project was to change provider practice in order to comply with the Medicare guidelines and to use the ODI to guide the plan of care for patients with facet-generated back-pain. The two-fold change, was first to provide educational training for the providers and staff in the use and purpose of the ODI in meeting compliance of a patient disability measuring tool, in relation to Medicare proposed requirements. And second was to identify ways that staff could ensure the use of the ODI at initial intake appointments and during post treatment. Methods: The project director (PD) performed a two-month post-initiation retrospective chart review and a four-month retrospective chart review to evaluate providers’ scoring and documentation of the use of the tool in the patients’ charts at intake and during post-treatment follow-up visits. The PD reported on the findings of provider and staff compliance with the use of ODI to providers and staff at regular intervals, two and four months after initiation. Outcomes: At the two-month review of charts, 99% of new patients were given the ODI to fill out in their intake data. By four months, compliance reached 100%. For every treatment group outlined in the project, incremental improvements were achieved by the four-month review. Unintended consequences experienced included that many patients did not return for their one-month follow-up appointment if they had shown significant improvement at the two-week follow-up. This skewed the data on the one-month follow-up appointments both at the two- and four-month reviews.
