Sarcopenia and the New ICD-10-CM Code: Screening, Staging, and Diagnosis Considerations

The ability to identify and document this geriatric syndrome in veterans will help to better define the scope of the problem within the VA health care system. The median age of veterans is 62 years compared with 43 years for nonveterans.³ Consequently, there may be value in the adoption of a formal approach to screening and diagnosis for sarcopenia among veterans who receive their primary care from VA facilities.⁷ Indeed, the exchange between the patient and the health professional regarding the screening and diagnostic process will provide valuable opportunities to promote exercise interventions before patients incur significant impairments.

One of the biggest threats burdening global health is noncommunicable diseases, and many chronic conditions, such as sarcopenia, can be prevented and managed with appropriate levels of physical activity.¹⁷ Increased physician involvement may prove to be critical given the identification of physical inactivity as a top 5 risk factor for general morbidity and mortality by World Health Organization and consensus group recommendations calling for physicians to serve a more prominent role in the provision of exercise and physical activity recommendations.^16,17

This developing health care role should include NPs, PTs, physician assistants, and other associated health professionals. It also should include collaborative efforts between physicians and rehabilitation practitioners concerning provision of the formal exercise prescriptionprescription and monitoring of patient outcomes.

Individuals with severe forms of sarcopenia rarely improve without intervention.⁶ Although no pharmacologic treatment exists to specifically address sarcopenia, strengthening exercise has been shown to be an effective mode of prevention and conservative management.⁸ Progressive resistance exercise cannot abate the expected age-related changes in skeletal muscle, but it can significantly reverse the loss of LBM and strength in untrained older adults and slow the age-related decline in muscle performance in older adult athletes and trained individuals.⁴⁵

Local senior centers and community organizations may prove to be valuable resources concerning group exercise options, and they provide the added benefit of social engagement and peer group accountability. Federal resources include the Go4Life exercise guide and online videos provided by the National Institute on Aging and the MOVE! Weight Management and Health Program provided at select VA community-based outpatient clinics. Ultimately, collaborative efforts with exercise specialists may serve to reduce the PCP burden during the provision of health services, minimize diagnostic errors associated with sarcopenia assessment and help to connect patients to valuable health promotion resources.^17,18

Conclusion

While practitioners should remain keenly aware of the pernicious effects of overdiagnosis, sarcopenia has long existed as a known, but undiagnosed, condition. Of course, geriatricians have traditionally managed poor muscle performance and mobility limitations by addressing treatable symptoms and providing referrals to physical medicine specialists when warranted. Nevertheless, the advent of ICD-10-CM code M62.⁸⁴ provides the VA with an opportunity to take a leading role in systematically addressing this geriatric syndrome within an aging veteran population.

The following items should be considered by NCP for the development of guidelines and recommendations concerning sarcopenia screening:

1. Consider screening veterans aged > 65 years for sarcopenia every 2 years. Those with mitigating systemic conditions (eg, chronic kidney disease, DM, or malnutrition) or significant mobility limitations may be screened at any age.
2. Sarcopenia screening procedures should include at a minimum the SARC-F questionnaire and gait speed (when appropriate). Including gait speed or grip strength testing in the screening exam is recommended given the low sensitivity of the SARC-F questionnaire.
3. Veterans with positive SARC-F results (≥ 4) merit a physical therapy referral. In addition, these veterans should obtain confirmatory standardized assessments for LBM and functional status.
4. Veterans at risk for sarcopenia based on patient age, medical history, and the physical examination (eg, obesity, sedentary lifestyle, a previous fracture, self-reported physical decline), but with negative SARC-F results should receive a formal exercise prescription from their PCP. Baseline assessment measures may be used for comparison with serial measures obtained during subsequent screening visits to support long-term case management.
5. Interprofessional collaboration involving geriatricians, PTs, nurses, radiologists, and other health care professionals should be involved in the screening, diagnosis, and case management of veterans with sarcopenia.
6. The VA EMR should be systematically documented with sarcopenia assessment data obtained from the gait speed tests, SARCF, SPPB, grip strength tests, and LBM estimates to better characterize this condition within the veteran population.

Any expansion in the provision of health care comes with anticipated benefits and potential costs. Broad guidance from NCP may encourage veterans to pursue selected screening tests, promote the appropriate use of preventative services, and facilitate timely treatment when needed.³¹ Clinicians who are informed about the screening, staging, classification, and diagnostic process for sarcopenia may partner with patients to make reasoned decisions about how to best manage this syndrome within the VA medical center environment.