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:
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.
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.