"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

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

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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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