"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

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.

Free Tutorial

Get free stuff at BulletproofPT.com

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.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.