"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Thursday, December 27, 2007

SIMPLE Describes Low Back Pain

The SIMPLE movements reflect a common problem.

The SIMPLE movements were derived from my observation that many patients in my practice suffered from disordered movement patterns that result from and contribute to lumbar spinal stenosis.

The interesting thing that I noticed after I had started to gather the data was that many patients who had not (yet) developed radiographic evidence of stenosis, nevertheless, displayed many of the same impairments in strength and range of motion as those patients who had a medical diagnosis of spinal stenosis from their physician.

Low back pain is an endpoint and lumbar spinal stenosis is the last step in the degenerative cascade that originates with disordered movements in our earliest years.

Patients present to many practitioners at points along the way to their penultimate point and it is my hope that SIMPLE can be used to describe the physical dimension of those points.

In my naiveté I persist in believing that if we can describe a physical process then we can change it.

SIMPLE Bias

At this point I should acknowledge an obvious bias in the SIMPLE system: an exercise bias.

SIMPLE is designed to provide the physical therapist with goals and interventions that are amenable to therapeutic exercise and (to a lesser extent) manual therapy.

This bias is not accidental.

The physical therapy profession is well positioned to lead the public in modern exercise attitudes and in movement awareness. Exercise is very nearly synonymous with the phrase ‘physical therapy’.

The connection between exercise and physical therapy exists, not because of advertising and marketing, but because of a real need and a demand for skilled exercise services.

The connection between exercise and physical therapy is not complete since the association with exercise is ‘flavored’ by athletic trainers, personal trainers, exercise physiologists, aerobics instructors, coaches and fitness gurus.

To control the domain of exercise then physical therapists need to measure movement.
If a physical therapist can tell their patient the exact amount and quality of their existing movement impairment then the physical therapist can prescribe exercise precisely to correct the impairment.

To measure movement physical therapists need simple and precise tools that determine the extent of their patient’s involvement and that can help decide the proper intervention.

In Outpatient Physical Therapy for Musculoskeletal Conditions, Stephanie Carter, PT, PhD says the following:

“It is not known how many people with musculoskeletal conditions actually need physical therapy services, and no criteria exist for making this determination”8


SIMPLE is predicated upon the following assumption:

The presence of impairments (with or without pain) should be the criteria for determining those people who need skilled exercise intervention.

The role of SIMPLE is to help physical therapists measure the presence or the absence of impairments that affect physical function and thereby become better decision-makers and better diagnosticians.

To physical therapists, physical therapy is much more than just exercise.

To physical therapists’ patients, however, physical therapy is just what physical therapists do.

The patient doesn’t know the difference and the patient doesn’t care.

The patient just wants to get better.

Tim

Tools for the Tool Box

The SIMPLE system of diagnosis was born as a Medicare compliance program for a Medicare Part B Physical Therapist in Private Practice.

I was the Compliance Officer and I was in the bulls-eye when the Medicare auditors would come knocking (they haven't yet, knock wood).

After surveying the current marketplace I felt that there were not sufficient tools that I could bring back to my staff to help them get to where I thought we needed to be.

At that point in time my main goal was to get a good nights sleep without worrying about a Medicare audit.

I wanted a tool that would enable my physical therapists and physical therapist assistants to become able note writers, goals-setters and intervention selectors without having to memorize all of the Medicare Benefits Policy Manual, Transmittal 63 (~ 45 pages).

Autopilot

The physical therapist's clinical decision-making and critical thinking skills should be focused on patient care, not on how to best write a legal note in the chart.

I developed the SIMPLE system as an answer to this problem.

The SIMPLE system allows the therapist to spend time with the patient collecting data and building the therapeutic relationship. Once data collection is completed selecting interventions and goal setting are automatic.

Diagnosis is the first step in the system that derives naturally from data that is easily obtained using skills familiar to the new graduate as well as the seasoned expert.

Diagnosis is communicated in standardized language that is familiar to the doctor, the nurse, the PTA and to the patient.

The SIMPLE system helps the physical therapist arrive at a diagnosis by measuring a standardized set of movements that reflect the patient’s ability to generate strength and move through a range-of-motion.

SIMPLE tries to capture data about the lower extremities and the lumbar spine.
Physical therapy diagnosis may include other body parts. The final section of Part 1: Clinical Skills describes Supplementary Positions and Measurements that can be used to diagnose other conditions commonly seen in physical therapy practice.

To study the SIMPLE system for free go to www.SimpleScore.com and view the videos.

Tim

Physical Therapist Doctor

It's December 27th 2007 and Physical Therapists are required to make physician-level decisions.

Physical therapists are required to determine the Medical Necessity for Physical Therapy as part of the physical therapy plan of care.

This level of decision-making requires a physical therapy diagnosis, assessment of physical impairments, functional limitations, patient co-morbidities and intangibles like motivation and aptitude.

Just like a medical doctor has tools like x-ray, MRI and blood tests to make the diagnosis the physical therapist needs tools to make the physical therapy diagnosis.

To learn how to assess physical impairments in range-of-motion and strength go to www.SimpleScore.com and view treatment videos.

Tim

Wednesday, December 19, 2007

You’re Crazy if You’re Not Paranoid

I just sent a note to my staff therapists.

We’re making a Medicare abbreviation list as a reference for anyone who needs to read our charts: therapists, case managers, back office staff or auditors.

The note said the following:

Please include any abbreviations you typically use in your charts for a list for when the Medicare auditors come


Not if, but when.

Because Medicare audits can be random or targeted and because physical therapists don’t fully understand the criteria for targeted audits.

That’s when it’s good to be paranoid.

When Medicare is concerned, it’s good to be paranoid.

Click here for the OIG Compliance Program for Individual and Small Group Physician Practices.

This document will describe the optimal compliance program for small private practice physical therapists.

I did get a little teasing from my peers for my choice of wording in the note.

The teasing was good-natured and the point was taken. Nevertheless, my recommendation is to design your Medicare compliance program with the end firmly in mind.

Design your compliance program as if you anticipate the worst.

At night I sleep well because in the daytime, at work, I’m paranoid.

Paranoia is a disturbed thought process characterized by excessive anxiety or fear, often to the point of irrationality and delusion. (Wikipedia, Web Accessed 11/30/07)

While these personality qualities are dysfunctional when applied to social relationships they are essential when applied to the mindset of your corporate Medicare compliance officer.

Create an abbreviation list. Mine is posted on this blog as 'Abbreviation List'.

Find other, creative ways to make your organization Medicare compliant. Make it easy for the Medicare auditor to give you a passing grade.

A little paranoia won’t destroy you.

It might save you.

Tuesday, December 18, 2007

How to use the OPTIMAL scale

video

This video demonstrates the OPTIMAL scale for the initial step in physical therapy diagnosis.

If you don't have written copyright permission to use the OPTIMAL (available for free from the APTA here)then you can use any other functional scale you like. You can even make up your own.

The OPTIMAL is my preference because it is 'recommended' by Medicare. Also, the psychometric properties of the OPTIMAL have been described, including descriptive statistics, measures of reliability, validity and responsiveness. Read the full text article here

Once you have the patient-identified functional limitations you can formulate your clinical hypotheses.

You take measurements in order to support or refute your hypothesis.

You design your plan of care based upon the measured impairments you discover in the course of your evaluation.

You re-measure the impairments to assess progress.

Ultimately, you re-measure the functional limitations (using the OPTIMAL).

The second OPTIMAL serves as a test of your original hypothesis.

Visit www.SimpleScore.com for video demonstrations of simple ways to measure common impairments in ROM and strength.

Tuesday, December 11, 2007

How to Diagnose Rotator Cuff Weakness

video

View the video to assess rotator cuff weakness. Note that your findings must correlate with the patient-stated functional limitation (eg: cannot raise the involved arm over the head).

The patient may also identify a disability, namely the inability to engage in work or play as a result of the functional limitation.

Please forgive the math error at the end of the video - I was a little nervous.

Tim

Monday, November 26, 2007

Is Your Physical Therapy Valuable?

Is Your Physical Therapy Valuable?

Medicare only wants to pay for physical therapy that prevents a decline in function and subsequent loss of independent living.

For example, physical therapy that keeps a Medicare beneficiary at home and prevents a transfer to a nursing home is valuable to Medicare because the level of care and skilled services in a nursing home creates higher costs for the Medicare system and for society in general. Valuable physical therapy can prevent this loss of independence

Medicare wants to pay for valuable physical therapy.

Medicare will buy as much valuable physical therapy as you are selling.

Physical Therapy is a “Black Hole”

Physical therapist Alfonso Amato says in IMPACT magazine (Vol.3, Issue 10) the following:

“…payors describe outpatient rehabilitation as a ‘black hole’: they don’t know what they are paying for, don’t know the benefit of the service, and don’t know when the patient has reached maximum benefit”


Currently, the measure of the value of your therapy is the detailed chart documentation that describes the change in functional limitations and the change in physical impairments.

Chart documentation is what auditors look at to determine if you should return your fee, or not.

Medicare does not want to pay for physical therapy that is not valuable.

Is your physical therapy valuable?

Your chart documentation will tell you.

Audit Yourself


Can you open your chart, read your note and determine from one or two entries why and what the patient is doing in physical therapy? Is the patient improving functional abilities? Are their impairments getting better?

Does each entry reflect the skill of a physical therapist or physical therapist assistant? Is the skilled service obvious?

Show the Medicare auditor that your chart is full of hard data, critical thinking assessments, skilled physical therapy examples and diagnosis-driven decisions.

Write them down.

For example, use the language from the Benefits Policy Manual (Transmittal 63) to describe improvements in functional abilities:

“Objective data that demonstrates improved functional abilities is the OPTIMAL score decreased from 2.5 to 1.5 in 4 weeks, as expected”


Put that statement in your discharge note.

Make it easy for the Medicare auditor to decide to move on to the next chart.

Low-hanging Fruit

Don’t be the ‘low-hanging fruit’ that the auditors love to pick on.

Make your chart documentation difficult to disprove.

Make the auditor work hard to find a fault in your critical thinking.

Build a strong case for the physical therapy that your patient needs.

Argue for the patient, in writing, with numbers, measurements and functional scores that demonstrate the following:

* Skilled physical therapy services each and every session.
* Medical necessity for physical therapy services (only needs to be noted in the plan of care).
* Expect significant improvement in a predictable timeframe.

Imagine the following scenario:

You are an auditor paid to find fault with physical therapy charts. You find that most physical therapy entries are handwritten, overly brief and directed towards patient symptoms and specific tasks, like exercise.

Your income is based on finding charts that do not demonstrate the above criteria.

Yours is a thankless job.

Now you’ve come across a chart that is full of detailed impairment measurements, functional scores and sharp assessments that show critical thinking by the physical therapist.

The Treatment Encounter Notes are mainly numbers that show bilateral measurements and are compared against initial values. Goals are referenced weekly. Interventions are described daily.

Progress Notes are sent every calendar month for re-certification of the Plan of Care and include statements of medical necessity and justify any exceptions to Medicare caps on spending.

Discharge Notes clearly state who got better, by how much and who did not get better. The medical necessity for the non-responders is clearly stated in each discharge note.

You realize this chart will be a lot of work.

You can quickly scan this chart for any obvious omissions but your chances of a significant recovery are better if you move on to a different chart (and a different therapist).

Who Knows Who

In some cases, Medicare physical therapy auditors are physical therapists. They know what good physical therapy looks like.

To minimize your chances of a significant, unfavorable post-payment audit you should try to provide the best physical therapy you possibly can provide.

Provide valuable physical therapy.

Write it down.

Valuable, written physical therapy will survive a Medicare audit.

Valuable physical therapy is better for your patients.

Sunday, November 18, 2007

How to Develop a Medicare compliance program

I developed a Medicare compliance program called the SIMPLE system so that the employees of my two outpatient physical therapy clinics in Florida (our website is at www.MedicalArtsRehab.com) would have an easy, reliable method of creating a clinically relevant audit trail.

In this post I’ll talk about how to develop a similar system. I’ll also talk about how and why I developed the SIMPLE system.

Details of the SIMPLE system, including videos, are found at www.SimpleScore.com.

SIMPLE stands for the Summary of Impairments of the Lumbar spine and Extremities.

Our Medicare compliance program automates many of the routine, written functions of the initial physical therapy encounter. The SIMPLE system starts with a physical therapy diagnosis that forms the basis of the Medicare compliant chart.

A physical therapy diagnosis will improve the physical therapy chart and subsequent documentation.

The ultimate goal is to create charts and notes that are ‘bulletproof’ when subjected to audit examination.

What is physical therapy documentation?

Documentation is any of the physical therapist written components that may go into the chart. These include the following:

1) Evaluation
2) Physical therapy diagnosis
3) Initial plan of care and subsequent changes to the plan of care
4) Subsequent progress notes
5) Subsequent re-certifications
6) Discharge note
7) Superbill or charge slips


Note that the physician’s diagnosis is not included in this list. While the medical diagnosis is important to the physical therapist it is left off of this list to dramatize the point that the physician cannot establish the medical necessity for physical therapy.

Superbills or charge slips are included because every charge must match a note entry that supports the skilled nature of the intervention. For example, a note entry that supports Therapeutic Exercise (97110) might look like the following:

“Left shoulder external rotation (ER) strengthening, 30 reps, with 2# hand weight. Manual assist (AAROM) at end range to achieve full ER ROM.”

Another way to demonstrate skilled intervention is through specific measurement.

Measurements may be taken at each session rather than at the end of the plan of care.

Physical therapist assistants (PTA) may take measurements as part of their data collection functions. Physical therapist assistants may make clinical judgments based on these measurements.

An example of physical therapist assistant clinical judgment might look like the following:

“The goal for shoulder external rotation PROM is 60o and today’s measurement is 30o. The measurement last week was 20o. Achieving progress towards goal.”


Note that the physical therapist assistant is not making any determination about whether or not to continue or change the plan of care. That is the job of the physical therapist.

Three criteria that demonstrate value to the purchaser

Physical therapy documentation is required to support three main criteria that demonstrate value to the third party payer.

These criteria are the following:

1) Medical necessity for physical therapy services
2) Skilled intervention at each treatment encounter
3) Expectation of significant improvement in a reasonable time period


The physical therapy evaluation is the essential process that culminates in the physical therapy diagnosis.

The physical therapy evaluation is a decision-making opportunity that too often is wasted. The opportunity is wasted if measurements are not taken that describe physical impairments and functional limitations. The measurements are the steps in the decision-making process that culminates in the physical therapy diagnosis.

The measurements also provide an opportunity for goal setting and for selecting interventions in the plan of care.

More detail in this process is at www.SimpleScore.com.in video and downloadable templates.

Resource list

There are multiple resources that anyone can use to develop a system such as the SIMPLE diagnosis system.

See my prior blog post here for a partial list to date of my reading list.

Perhaps the most obvious resource is the observation that common clinical conditions such as low back pain are frustrating and complicated for the average physical therapist.

New graduate physical therapists and seasoned professionals are similarly stymied by the low back pain diagnosis.

Additionally, wide treatment variation exists in the choice of interventions given to patients diagnosed with low back pain.

Who, What, When, Why and Where

The routine use of a physical therapy diagnosis is supported by…

1) measurement of impairments in range of motion and strength
2) measurement of functional limitations.

The routine use of a physical therapy diagnosis will do the following:

1) improve physical therapist understanding of what we treat
2) improve physical therapist agreement on how we treat
3) improve third party payer understanding of why they should pay
4) improve patient understanding of when to address physical impairments (before surgery)
5) improve physical therapists competitive position in the healthcare marketplace where physical therapists are perceived as offering a precise and measurable system of exercise and movement intervention.


The resource list in the preceding post may help to supplement and support the processes used to develop a Medicare compliance program and the SIMPLE diagnosis system.

Resource list for Physical Therapy Diagnosis

1) Cyriax’s Illustrated Manual of Orthopedic Medicine, 2nd edition. Butterworth Heinmann, London. 1993.

2) Medicare Benefit Policy Manual. Pub 100-02, Transmittal 63. 29 Dec. 2006.

3) Local Coverage Determination for Rehabilitation Therapy. Blue Cross and Blue Shield of Florida and Connecticut. 2007.

4) Guide to Physical Therapy Practice, 2nd Edition, Phys Ther. Vol. 81, No1. Jan 2001.

5) Commission for the Accreditation of Physical Therapist Education (CAPTE). Accreditation Handbook, April 2004.

6) Sandstrom RW. The Meanings of Autonomy in Physical Therapy. Phys Ther 2007; 87: 98-110.

7) Amato A. Value Purchasing in Outpatient Physical Therapy. IMPACT. Volume 3. Issue 10; 8-12.

8) Carter S. Outpatient Physical Therapy for Musculoskeletal Conditions. Phys Ther. 2007; 87(5): 498- ?

9) Coffin-Zadai CA. Disabling Our Diagnostic Dilemnas. JOSPT. 2007; 87(6): 641-653.

10) Newman D, Allison SL. Risk and Physical Therapy. JOSPT. 2007; 37(6): 287-289.

11) Department of Health and Human Services, Office of the Inspector General, Compliance Program for Individual and Small Group Physician Practices. Federal Register, Vol. 65, No. 194. 2000.

12) Defensible Documentation for Patient/Client Management. American Physical Therapy Association. Web Accessed 12/11/2006.

13) Norton BJ. Diagnosis Dialogue: A Progress Report. Phys Ther 87(10): 1270-1273. October 2007.

14) ? Phys Ther Vol. 87 (1). Jan 2007. pp. 9-23. (reference nerve root impairments)

Saturday, November 10, 2007

Diagnosis by the Numbers

“I often say that when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of Science, whatever the matter may be.”

William Thomson, 1st Baron Kelvin

Why are numbers better than words in describing skilled physical therapy services?


Let me count the ways.

Numbers are independently verifiable.

The physical therapy tools used in the clinic (eg: tape measure, goniometer, ruler) tend to have acceptable inter-rater reliability.

That means that Sergio can take a measurement during one session and Maria can take a measurement the next session and expect to get close to the same value.

Continuing that line of reasoning, Sergio can diagnose a short hamstring, using measured values, and Maria can base treatment decisions on Sergio’s diagnosis.

Numbers are more precise than adjective descriptors

‘Hypermobility’ truly exists but is more apparent to a patient, doctor or student physical therapist when we measure 110o hamstring right and 112o left range of motion.

If normal hamstring straight leg raise values cluster around 90o and hamstring flexibility can be used as a proxy for capsulo-ligamentous composition then a simple comparison of measured versus normal values would lead to a diagnosis of hypermobility.

Numbers show patterns of ROM and strength that are not evident to a non-physical therapist

Compare the active external rotation of a shoulder against gravity (for instance in a sidelying position) with that same motion with a two-pound dumbbell weight in the hand. Any measured difference would imply the loss of strength in the external rotator muscle.

An example may help to show the procedure.

Ricardo lays down on his left side and raises his right arm 60o in external rotation. Sergio, his therapist, helps him through the range to ensure the best possible measurement.

This video shows the exact procedure.

Ricardo then holds a two-pound weight and raises his right arm, as best he can, in external rotation. This time Sergio does not help Ricardo. Sergio measures 30o with the goniometer.

The calculated difference (60o - 30o = 30 ) is a quantifiable strength deficit that may be amenable to therapeutic exercise strengthening.

The physical therapist would use this measured value to render a physical therapy diagnosis that linked the measured impairments with the measured functional limitations.

Numbers show quantifiable progress (or lack thereof)

To continue the preceding example let’s pretend that it is now two weeks later.

Sergio needs to demonstrate that Ricardo is making progress with physical therapy within the expected timeframe (Ricardo is a Medicare patient). Sergio re-measures Ricardo’s external rotation with the 2# weight. Ricardo can now lift the weight 45o in external rotation.

Sergio should document the procedure and the measurement.

I don’t like SOAP notes - they encourage an overly brief style of note writing. Dr. Steve Levine says that SOAP is for the shower.


Nevertheless, I will demonstrate the SOAP format using numbers to demonstrate the following:

1) Medical Necessity for Physical Therapy

2) Demonstrates progress within an expected timeframe

3) Skilled physical therapy services

SOAP note:

S: “I can now dress myself in the morning because lifting my right arm is easier and less painful”

O: Ricardo demonstrates dressing maneuver in the clinic without pain behavior.

External rotator strength has improved since Ricardo can now externally rotate right shoulder 45o with a 2# weight.

A: Goal #1 is 50% met.

P: Increase to a 3# weight.

Note that my note is overly brief. I did that on purpose to emphasize the impairment measurement we just took for shoulder strength.

Subjective give disability information that physical therapists don’t usually measure directly.

Objective gives functional limitation and impairment information that is measured with OPTIMAL scores, goniometers, tape measures, SIMPLE and other common, clinical tools.

Assessment addresses progress towards goals.

Plan modifies the plan of care.

Numbers provide an audit trail to support Medical (Physical Therapy) Necessity

The Medicare Benefit Policy Manual (Transmittal 63) states the following:

“Objective evidence consists of
  1. standardized patient assessment instruments
  2. outcome measurement tools
  3. measurable assessments of functional outcome.

Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.

Such tools are not required, but their use will enhance the justification for needed therapy”

Medical necessity denials are one of the largest component of pre and post audit denials. The Office of the Inspector General monitors this kind of stuff and released this incriminating report here.


The physical therapist should make it easy for the auditor to understand why physical therapy is necessary for the patient and what is the intended effect of the physical therapy plan of care.

Physical therapy is not rocket science.

Physical therapy diagnosis is simple.

Use numbers to make physical therapy notes and charts simple, too.

Monday, October 29, 2007

HealthSouth Sells Physical Therapy

For those who didn't see my article in the October 2007 Physical Therapy Products Online here is the link to Stay Small and Make Big Profits.

The day the article ran I got an e-mail from a former Vice President of Operations at HealthSouth who took issue with my analysis.

He said it was incomplete.

What I couldn't know from studying the 2007 HealthSouth Annual Report was that the firm couldn't hold onto talented, ethical therapists. He said physical therapists were leaving in droves and the ones that remained couldn't compete with the smart, tough local independent physical therapists.

He said he had opened his own clinic and was competing successfully against his former employer.

He had become one of us.

Thursday, October 25, 2007

The Disablement Model

The Disablement Model

The Disablement Model is a great way for physical therapists and physical therapist students to begin thinking about physical therapy diagnosis.

My undergraduate physical therapy education at the University of Florida in 1992 did not have any mention of Nagi or WHO (World Health Organization) or the process that leads from tissue pathology to physical handicaps.

Physical therapist assistants, however, that graduate in 2008 will have had 4 semesters of information that is permeated with information on the disablement model and they should be comfortable with practice patterns that incorporate ‘disablement thinking’.

Disablement thinking was a concept in 1992 but disablement thinking should be common practice in 2008. If physical therapists are not practicing with disablement concepts firmly in mind then it is because there are not sufficient tools in place to bridge the gap between concept and practice. I have designed the SIMPLE system to be one of those tools.

The SIMPLE system is a decision-making tool for physical therapists to decide on a diagnosis, to decide on goals and to decide on physical therapy interventions.

Pathology doesn’t do a good job of guiding the decision-making process for the physical therapist (see Sandstrom RW in PT Journal).

The Nagi Model

The SIMPLE system adheres to the Nagi disablement model and to the Guide to Physical Therapist Practice regarding the relationship among disability, functional limitations and impairments.

The SIMPLE system also adheres to the recommendations in the latest updates to the Medicare Benefit Policy Manuals and in the state-specific Local Coverage Determination
(here is the link for Florida) for the purpose of creating compliant physical therapy plans of care and for physical therapy goal setting.

Begin with the physical therapy diagnosis


The diagnosis is the link between the measured impairments and the measured functional limitations. The SIMPLE system cannot make the diagnosis – only the physical therapist can make the diagnosis. The SIMPLE system automates the charting and the documentation once the physical therapist makes the diagnosis.

Physical therapists’ time is far too costly and their expertise too valuable to spend in their back office making up new goals for certain high-volume diagnoses.

Physical therapists need an easy way to put on paper the skilled stuff they do with patients. If a physical therapist doesn’t have to worry about “What do I have to write down to pass a Medicare audit?” then they can spend more time with their patient doing the skilled care that gets people better.

Skilled care is not complicated but it is hard work. Medicare documentation is complicated but it doesn’t need to be hard work. Not if you use the SIMPLE system.

It’s a simple process.

It’s a simple system.

Bottom line, it’s better physical therapy.

Tim Richardson, PT

Tuesday, October 23, 2007

Who Needs Physical Therapy Diagnosis? (Part 1)

The Physical Therapy Diagnosis
Who needs physical therapy diagnosis?
Who, beside the physical therapist and the patient, needs a physical therapy diagnosis?
The doctor needs the physical therapy diagnosis from the physical therapist.

Physical therapy diagnosis helps the doctor.

The physical therapy diagnosis helps the doctor because the diagnosis is stated in universally understood terms (eg: range-of-motion and strength). The physical therapy diagnosis avoids medical diagnosis (eg: tendonitis) and so the physician is not threatened or offended.

Diagnosis systems which invent specific terms to describe commonly encountered clinical phenomenon are too complex for the busy physician or the distracted patient to try to learn.

Physical therapy diagnosis helps the new graduate physical therapist.

Simple physical therapy diagnoses (eg: shortened hamstring muscle) encourage new graduates and those older graduates who may not have taken advanced orthopedic physical therapy coursework to make their initial diagnosis.

As the new graduate begins to gain confidence in their diagnostic skills they will naturally progress to recognized patterns of impairments that tend to occur together. This pattern recognition will make the diagnostic process faster and easier.

Automate the decision process

Making a physical therapy diagnosis at the initial evaluation improves the decision-making process by automating the goal setting and the choice of interventions. Diagnostic decisions flow automatically from a limited number of options that apply to measured impairments, for example: a shortened hamstring muscle can be treated with the following interventions:

  1. Manual Therapy (97140), massage or myofascial release.
  2. Therapeutic Exercise (97110): passive or active range-of-motion, stretching exercises or progressive resistance exercise.
  3. Neuromuscular Reeducation (97112) to lengthen the hamstring with a stable lumbar spine.


The goal would flow directly from the measurements. For instance, if the right hamstring has 70 degrees straight leg raise and the left hamstring has 90 degrees straight leg raise then the goal would be written as follows:

Increase right hamstring straight leg raise from 70 to 90 degrees.

Another Example.

For example, a patient comes in with heel pain.

You measure the fastest, easiest metric for the foot: Standing Heel Raise. You obtain the following values:

Standing Heel Raise: 6cm Right
10cm Left

Standing heel raise is a standardized measurement that purports to describe the strength of the posterior leg muscles and the range of motion of the ankle joint.

Our measurement indicates that the posterior leg is weak. The initial goal of therapy should be to strengthen the weak muscle.

The physical therapist would set the first long term goal of therapy as follows:

Strengthen the right Standing Calf Raise from 6cm to 10cm.

Cut Scores

Ten centimeters is the ‘cut score’ that defines a treatment success or a treatment failure. Cut scores can be determined empirically or statistically (See Risk and Physical Therapy by Newman and Allison).

The physical therapist selects the appropriate intervention to meet the long-term goal. In this example, therapeutic exercise is the most appropriate intervention for calf strengthening.

The documented description of the intervention would read as follows:

“Therapeutic exercise for strengthening the right calf muscle.”

The description of the intervention would need to be noted in the plan of care but not in each subsequent note (see Medicare Benefit Policy Manual Transmittal 63).

The diagnosis is predicated on good measurement. With good measurement and good diagnosis the physical therapist can do the following:

  1. Set goals
  2. Select interventions
  3. Determine progress by periodic re-assessments
  4. Make predictions about the future
  5. Give a discharge diagnosis

Automating the decision process with good measurement and good diagnosis allows the physical therapist to personally step back from the patient outcome. The physical therapist can identify and measure the impairment and link the impairment to the functional limitation.

The process of selecting the interventions that will best address the impairments and the functional limitations becomes a negotiated interaction between the physical therapist and the patient.

Physical therapy diagnosis de-emphasizes the importance of modalities. I’ve never seen a muscle get stronger with ultrasound.

A Final Example


Another example should help make my point.

My last patient this morning had the following diagnoses:

  1. Weak bilateral hip internal and external rotator muscles
  2. Weak bilateral hip abductors
  3. Weak left hip flexor muscle
  4. Short left hamstring muscle
  5. Stiff bilateral trunk rotation range-of-motion

I made these diagnoses with precise measurements. I compared the measurements to a ‘cut score’ from a large sample of patients. Any value that failed to reach the cut score for range-of-motion or strength was ‘weak’ or ‘stiff’ or ‘short’.

The point is that this patient had many physical impairments. Obviously she also had profound disabilities and severe pain. No amount of ultrasounds or hot packs will ever improve these impairments.

A physical therapy plan of care that is built around modalities will undermine the urgency of improving the true cause of the pain and the disablement: impairments in strength and range-of-motion.

Wednesday, October 17, 2007

Group Coding for Dummies

If you don’t use the group code (CPT 97150) in outpatient physical therapy billing and you dovetail treatments (every :30 minutes) then your company’s behavior sends a message to your employees

The message is this:

We don’t believe our charts and documentation are sufficiently well-written to survive a Medicare (Part B) audit. Also, we aren’t sophisticated or intelligent enough to learn and understand how to correctly code and document the group code.

Fly Below the Radar

Your employees will correctly perceive your corporate compliance strategy is ‘flying below the radar’ – don’t bill it so we don’t get caught. The unspoken secret is that there may be other areas where your Medicare compliance is less than optimum. You would rather give up group code revenue rather than invite suspicion on your other, ‘less risky’ coding patterns.

Rather than give up any revenue why not just learn the appropriate billing strategy and the appropriate way to chart the visit?

The reader can look to the Center for Medicare and Medicaid Services (CMS) Part B PT/OT group coding scenarios at this link: CMS Group Billing Scenarios.

This link has Center for Medicare and Medicaid services official interpretation of many physical and occupational therapy treatment scenarios.

Medicare vs. Everyone Else

What if you bill group code to Medicare patients but not to any other patients?

The Common Procedural Terminology (CPT) codes, created and defined by the American Medical Association (AMA), are not the exclusive province of Medicare. Therefore, you should apply the group code without regard to who pays for the physical therapy service.

The AMA is a professional association that generates revenue from creating, designing and promulgating CPT codes. They don't enforce the codes.

A legal issue probably arises in the insurance contracts that each physical therapist signs with each (non-Medicare) insurance company. The contract may contain language that states the eligible beneficiaries are not to be discriminated from any other patients.

For example, one of my contracts with an insurance company states the following:

"Responsibilities of the Provider:

1) Provide Medically Necessary Health Services to Covered Individuals in a manner similar and within the same time availability in which health care provider provides such services to any other individual and XYZ Co. Provider will not discriminate or differentiate against Covered individuals"

In other words, neither the AMA, the American Physical Therapy Association (APTA) or CMS will care if you treat Medicare patients better than non-Medicare patients. That is, if you are compliant with Medicare ‘rules’ then there are no grounds for CMS to take action.

You may, however, be in violation of your contractual obligations to the insurance company. You may also be in violation of the APTA Code of Ethics.

Principle 2 states the following:

“A physical therapist shall act in a trustworthy manner towards patients and in all other aspects of physical therapy practice”

Principle 3 states this:

“A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients”

Red Flags

Many of my friends and peers, physical therapists in private practice, have admitted to under-billing the group code because of its perceived ‘red flag’ status.

I think this is a mistake. Know the rules. Follow the rules.

Knowledge is power. Use it.

Tim Richardson, PT

Tuesday, October 16, 2007

Simple Beginnings

SIMPLE begins with a diagnosis – a diagnosis of a sick practice.

I was more eager than I was experienced when, in 2006, I bought controlling interest of my physical therapy clinics (3 of them) from our founding partners (2 of them).

After closing the sale the three of us were sitting around a large wooden conference table having a pleasant chat when one of the founders made this comment:
‘Our charts would never stand up to a Medicare audit’.


I can recall the frantic desire to find and tear into pieces my check and all the closing documents that we had just signed.

From that moment on I dedicated myself to developing a system that could reliably train and motivate my seven physical therapists and physical therapist assistants to quickly and completely create a Medicare compliant plan of care, daily note and discharge.

Most importantly, the system had to be based on the patient’s needs so that the therapist was allowed to do what the therapist does best: care for the patient.

I wanted a system that allowed the PT and the PTA to work together, using the clinical decision-making of the PT and the clinical judgment of the PTA5. I also felt the system needed to be diagnosis-driven from the start. A physical therapy diagnosis, that is.

I want to be able to share this system with my peers who own or manage their physical therapy clinics and who might not have access to a sophisticated corporate compliance department.

What I hope to present here is a standard process of measurement, diagnosis, goal setting and selection of interventions that displays both a rigorous thought process and an intuitive understanding of Medicare (and of the common needs of all third party payers, both commercial and federal).

Finally, the system should to both the experienced clinician and to the new graduate.

Tim

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"


Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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