What will replace the OPTIMAL?

I get a lot of feedback on this blog from physical therapists who don't much like the OPTIMAL scale.

Some say they use it because it's 'recommended' by Medicare, not because it's a good outcomes scale.

Some of the problems with the OPTIMAL scale that physical therapists relate to me are:

• Too general
• No descriptors of the activities (eg: long distance walking)
• Inappropriate for elderly persons (eg: running, hopping and jumping)
• Too long (21 activities)
  

This is just a short list...

Additionally, the American Physical Therapy Association has gone on record saying the OPTIMAL has not fulfilled its intended mission:

...to be the single, disease-specific treatment planning and goal-setting tool for outpatient physical therapy Medicare compliance and outcomes measurement. (my emphasis)

Nevertheless, the APTA maintains the OPTIMAL page on its website and offers free licensing for clinical physical therapy use until a superior alternative is found.

What are the alternatives?

Now, be aware that these are commercial (NOT free) alternatives that offer some enhancement over a pen-and-paper tool like the OPTIMAL.

CARE tool (May 2009)

AM-PAC (required by 2012?)

FOTO

There may be others, like the following:

• Neck and Back Index
  
• Oswestry scale
  
• Lower Extremity Functional Scale
  
• Patient-Specific Functional Scale

...and others, that are acceptable overall outcomes measures but are not recommended by Medicare.

Acceptable outcome measures have usually gone through the peer review process and are published in a professional journal and are accepted by a consensus.

What is the trade-off?

The trade-off for comprehensiveness is time.

A tool that is disease-specific requires multiple templates for different body parts or regions (eg: Neck and Back Index).

A tool that is more comprehensive is longer and harder for the patient to complete.

A longer tool may be more difficult for the clinician to score.

A commercial tool, today, offer few benefits over the free tool.

The OPTIMAL is brief and simple to score.

My own recommendation, today, is for the clinician to use the OPTIMAL.

What is the time frame?

In May 2009, Research Triangle International (RTI) will begin a pilot project to develop a new measurement tool to find

"...better information tied to patient need and the effectiveness of outpatient therapy services."

Between 2012 and 2014 the pilot project will wrap up and, presumably, physical therapists will have a needs-based, risk-adjusted tool to assess their patients, in acute, hospital-based and outpatient clinics.

What if you do nothing?

Even if you don't adopt a commercial tool today that, realistically, will segue into the recommended tool by 2012 you should be using the free tool.

Doing nothing is not an option.

A Medicare auditor looking at your files may consider the absence of any outcomes tool as 'blatant disregard' of published recommendations.

Get your systems in place now.

The easiest, simplest system today is the OPTIMAL baseline and follow-up scale.

Use outcomes measures to measure your effectiveness because it's good physical therapy.

Use outcomes measures to improve your Medicare compliance because you can't afford not to do so.

Can Physical Therapists Treat Pain?

When I attended the University of Florida one of my physical therapy professors gave me this advice:

“Treating pain is a moral decision that may not be your primary therapeutic focus – treat function, not pain.”

At the time I wondered what my professor meant – treating physical dysfunction as the cause of pain in a way that alleviated the pain itself. This was a technique that eluded me for several more years.

I graduated from my university in 1992 without the benefit of learning the International Classification of Impairment, Disability and Handicap model (ICIDH) from the World Health Organization (WHO) for decision-making.

The ICIDH was first published in 1980 but it was intended for coding and manipulating data (eg: treatment codes), not for treatment decisions.

In 2001, WHO updated the ICIDH framework and re-named it the International Classification of Functioning, Disability and Health (ICF).

In June 2008, the American Physical Therapy Association (APTA) endorsed the ICF model.

“The model acknowledges that every human being can experience some level of "disability" and views functioning and disability as an interaction between health, the environment, personal and social factors.”

The new ICF framework, in my opinion and the opinion of others, greatly improves physical therapists’ ability to make treatment-planning decisions in the clinical setting.

“In clinical settings ICF is used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement.”

Making correct decisions as to the choice of treatment intervention at the initial evaluation will speed the acquisition of good patient handling skills and, ultimately, the collection of good data.

The evidence for function

Physical therapists consistently demonstrate an ability to improve function, reduce costs and healthcare utilization and generate satisfied patients. Physical therapists achieve these outcomes by focusing treatments on measured functional deficits.

Note: The references are available in the Bibliography at www.BulletproofPT.com.

Jewell DV and Riddle DL examined 1,804 patients diagnosed with sciatica and their response to physical therapy. Twenty-six (26%) of the patients (n=473) had a meaningful response on a follow-up questionnaire.

Patients who received joint mobility interventions and exercise were more likely to improve on the follow-up questionnaire than patients who received ‘spasm reduction’ interventions. Spasm reduction interventions included ultrasound, electric stimulation, heat and ice.

Another study, this one by Deyle GA et al reported on two groups of patients with knee osteoarthritis – one group received ‘manual physical therapy and exercise’ while the other group received de-tuned ultrasound. Eight weeks later, the treatment group receiving manual physical therapy and exercise improved 55.8% on the outcome questionnaire and 13.1% in distance in a six-minute walk. The control group that received de-tuned ultrasound showed no improvement.

A follow-up study by Deyle GA et al showed the effectiveness of skilled physical therapy over a home exercise program in 134 patients. By eight weeks the clinic treatment group had improved 52% while the home exercise group improved only 26%.

Subjects in the clinic exercise group were less likely to be taking their medications and were more satisfied with the results of their rehabilitation.

Finally, Fritz et al showed in a sample of 471 patients with acute low back pain that ‘adherence to the recommendation for active care’ decreased physical therapy visits, lowered physical therapy charges and led to greater improvements in pain and disability. A one-year follow-up showed that patients receiving ‘adherent care’ were associated with lower prescription medication usage, fewer MRI scans and fewer epidural steroid injections.

The evidence for pain

One study, cited by Medicare in its Physicans’ Quality Reporting Initiative (PQRI) Summary of Quality Measure Reporting Provision for 2009, instructed physical therapists and other eligible providers to assess pain prior to the initiation of therapy.

The Summary states the following:

“Reducing the intensity of pain by just 25% has been shown to achieve a 50% improvement in functional status”. 

Treat pain and measure function

One wise therapist helped me understand that we can do both - treat pain and measure function.

Physical therapists too often feel compelled to treat pain with modalities and throw in exercise and functional training if there is any time or dollars left over.

Pain is an impairment – an impairment that can be measured.

Pain is, however, just one impairment of many impairments that can be measured using new tools available to physical therapists.

Available tools (both free and paid) include the following:

• OPTIMAL difficulty and confidence scale (free)

• AM-PAC mobility and activity scale (paid)

• ICF disability framework (free)

• APTA Interactive Guide to Physical Therapist Practice, With Catalog of Tests and Measures (paid)

• FOTO (paid)

Futhermore, according to the ICF, pain will affect patient activities and participation differently in different people.

For a Bulletproof Chart, both pain and function can and should be measured.

Treating pain by improving function and movement is one of the essential skill sets of the physical therapist.

The physical therapist, using skilled decisions and judgment, links the various measured elements using the physical therapists’ diagnosis.

A physical therapist sticks to his knitting

I hang with physical therapists.

I stick to my knitting.

Here at Physical Therapy Diagnosis I try to provide the point of view of a private practice physical therapist trying to understand and cope with the United States health care system in general and Medicare in particular.

Lately, I've blogged a lot about the Medicare Recovery Audit Contractors (RACS).

Sometimes, though, you may want the full story - a comprehensive approach.

I've linked to this timely update on 'news' involving the RACs.

This blog offers a timely update on RACs, primarily on their impact on long-term acute care hospitals.

Keep looking at all the posts on this blog for some in-depth analysis of RACs and their specific impact on physical therapists.

How do physical therapists make decisions?

Physical therapists (PT) usually treat 11-15 patients per day in outpatient orthopedic clinics.

Most PTs in the United States still use a pen-and-paper approach to note writing.

We scribble all day long in between running to patient treatments.

Medicare only has these written notes to examine to determine if the physical therapy treatments are worth paying for.

What do most PT charts look like and what decisions do they reflect?

Get some perspective

Step back for a minute.

Stop writing your note.

Stop being a PT or PTA.

Look at your chart.

What does it look like?

Is it organized?

Neat?

Sequentially organized?

Are the most important documents on top?

Does it look like you chart is designed for fast, efficient treatment?

Or, does it look like your chart is designed for fast, efficient decisions?

What do skilled physical therapy decisions look like?

Your skilled physical therapist decisions are what Medicare is paying for.

Treatment is secondary to your decisions.

Make the chart work for you.

Set up your chart so that evidence of decision-making is foremost.

Put your goals at the front of the chart.

Make decisions about goals in the daily note. If you still use a SOAP note the Assessment portion should reflect progress towards goals.

Make your initial measurements accessible. Put your dictated Plan of Care where you can get to it easily (hint: not at the back of the chart).

Two types of measurement need to be accessible:

1. Impairment in body structure and function (ICF)

2. Activity and participation limitations (OPTIMAL)

Put these near the front of the chart.

Some therapists feel that the back of a double-sided, flip-type paper chart is just as accessible by grabbing the whole stack of paper and flipping it up.

Perhaps it is.

I think that putting your goals and measurements at the back of the chart however sends the subtle message that you see writing about goals as less important.

Goals are less apparent and less evident at the back.

The presentation of your chart should reflect your intent.

What is your intent?

Decisions or treatment?

Decisions are more defensible.

*****

To get an incredibly detailed, voluminous, technical and shelf-worthy resource on physical therapy do-it-yourself Medicare compliance go to the

Compliance Program for Individual and Small Group Physician Practices

by the Office of the Inspector General.

To get a compliance program written by a physical therapist for physical therapists go to

BulletproofPT.com

written by Tim Richardson, PT.

Own Your Own PT Clinic

Own your own PT clinic.

Owning your clinic is the dream of many smart, young physical therapists.

Treat how you feel your patients should be treated.

Do good work.

Get paid.

That's how I got started.

But I started with partners and I bought them out.

Out with the old and in with the new.

That's what I thought, at the time.

It was all mine.

*****

Then I looked around.

And there it was...

Something old, still there.

Sitting on the shelf, dusty.

An old three-ring binder.

Pages yellow with age.

When I opened it, I sneezed.

Dust flew off of the page, around my eyes.

It was the old clinic Medicare compliance manual.

Never opened.

Never updated.

Inside were ten, yellow typewritten pages.

Typewritten... On a typewriter.

The Manual

The pages contained, believe it or not, instructions on how to assemble hot packs and instructions to aides on how to treat patients.

There was actually a copy of a referral pad with a physicians' signature line that stated the following:

"These treatments are Medically Necessary for the patient to receive physical therapy services."

There was a diagram of the floor plan with the fire escapes marked in faded red marker.

The manual had one page that told what to do in the event of a hurricane.

It had another page that listed vacation days.

Wow.

The Date

I found a date.

1988.

That's when I started to panic, a little.

My Action Plan

I decided to get busy building a plan.

I took a seminar by an expert Medicare consultant.

According to the expert, my notes were so far out of compliance there should have been a red, neon label that said "Audit Me!" attached to every charge I sent to Medicare.

That's when I started to panic, a lot.

I decided to learn everything I could about outpatient physical therapy Medicare compliance.

I took more seminars, bought books, read newsletters, called my practice association and, in general, specialized in outpatient physical therapy Medicare compliance.

I excitedly went to my staff, 7 PTs and PTAs.

I told them everything I had learned.

You know what happened?

Big yawn.

Some PTs and PTAs fell asleep during my presentation.

Some were more polite about their disinterest.

Bottom line, the notes and charts didn't get much better.

Why?

It didn't matter.

I hadn't shown my staff why and how Medicare compliance made better physical therapy.

I hadn't shown my staff how they could help their patients more with better notes.

My PTs and PTAs just wanted to treat patients.

They couldn't see why and how notes could help them do that.

I had to do better.

I went back to the drawing board - I made Bulletproof Physical Therapy Notes and Charts.

Bulletproof is uses three, public-domain tools to show physical therapists' decisions - the core of your skill set.

Bulletproof uses templates to show progress and need for PT.

Bulletproof also describes dozens more tips, techniques and strategies for physical therapist mangers and educators to train PTs and PTAs to get Bulletproof Notes and Charts.

There is no three-ring binder to keep from getting dusty.

So far, the results are very encouraging.

My staff and my patients are happier than ever.

We are confident now when we append the -kx modifier, start a second month of therapy or just write a daily note.

Now, I'm not scared anymore.

Finally, I'm living the dream.

How much do RACs cost private practice physicians and physical therapists?

I've been living under the gun for three and a half years.

The RAC gun.

The Medicare Recovery Audit Contractor (RAC) program is a new permanent federal program expected to 'go live' in February 2009.

The initial roll-out is mainly in the northeast and in the RAC demonstration states.

I live in Florida, a demonstration state since 2005.

Recent conversations I've had with my peers and professional organizations indicate that there is a lot of additional anxiety regarding the RACs.

While I never want to downplay the severity or the possibility of a Medicare audit, MAC or RAC, I want to present some information that can help private practice physical therapists assess the risk of and the damage from the RACs.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

Data for this table is available in this report.

Note that physical therapists are lumped in with physicians in the RAC report from which this data is drawn.

$992.7 million dollars in overpayments were recovered from providers, mainly (85%) inpatient hospitals.

Of the $992.7 million only $19 million came from physician practices (which include physical therapists).

40% ($391.3 million) of the overpayments were for medically unnecessary services.

Services are medically unnecessary when the clinician failed to justify why the services were performed.

For physical therapists this usually means measurements of ROM or strength deficits.

Also, measurements of activity limitations.

Finally, link deficits to activity limitations in the physical therapists' diagnosis.

Bulletproof Compliance

Your current Medicare compliance plan should be sufficient to respond to a RAC audit.

If you have a current Medicare compliance plan.

Mine used to be a dusty manila file folder sitting up on a shelf.

Not anymore.

I got busy and got some basic education - available in this blog and at Bulletproof PT.

Get your own compliance program.

Get Bulletproof.

I live under the gun...

But, I sleep well.

Medicare RAC nightmare

I woke last night, sweating and afraid.

I felt my heartbeat pounding in my chest.

I had a nightmare.

I think I cried out because my wife woke, mumbled something and reached out to pat my leg.

In my nightmare, Medicare Recovery Audit Contractors (RAC) were in my PT clinic threatening hefty fines and jail time.

Paper lay in piles all over my office. Charts were open and strewn about on desks.

Copy machines hummed and glowing lights illuminated stern-faced auditors with green eyeshades.

"You're in a lot of trouble Mr. Richardson, did you know that?"

Of course, it was just a nightmare.

I wasn't actually being audited by Medicare RACs.

Some private practice physical therapists may share my anxiety.

For us, the threat of a RAC audit looms large as the expected February 2009 nationwide RAC roll-out approaches.

So what, in the bright light of day, are the known risks of a physical therapist RAC audit?

Here are some of the resources I have compiled to help physical therapists understand RACs.

Hint: It's not all bad.

Outliers

Medical Necessity

Who gets caught?

Advance Beneficiary Notice

Patient Case

RAC expansion schedule

RAC Fact Sheet

OIG Work Plan

Bulletproof Physical Therapy Notes and Charts

Does Physical Therapy Cost Too Much?

Some physical therapists over-treat their patients.

The most expensive Medicare physical therapy patient in America received $114,799 in services in 2004.

By 2006, the most expensive Medicare physical therapy patient in America only cost $37,543.

The difference in 2006 vs. 2004 was the implementation of the 'per beneficiary caps' on outpatient rehabilitative services.

The chart header below reads 'Annual Per Beneficiary Payment Threshold Change Per Percentile' and it shows the amount of physical therapy received, in dollars, broken down by percentile.
The next chart is the same data set, with the 100th percentile removed.

Notice how the chart scale shifts and the differences between 2006 vs. 2004 are made apparent.
These two charts are taken from data provided by the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2)

The data for these charts is available in the OTAPS 2 report as Table 3.

I extracted and re-formatted the data as two separate charts to illustrate the impact of the 100th percentile cost outliers.

If these charts are too hard to read I have put them as PDF files at www.BulletproofPT.com.

Falling Costs

Note how costs for physical therapy have fallen across the board.

The exceptions to falling costs are those patients whose costs are below the 50th percentile (median).

Their costs are rising.

At the 50% percentile costs increased at about the same rate of growth as the overall Medicare population (3.5%).

At the 25% percentile costs increased at double the rate of growth of the overall Medicare population.

Why?

Who cares?

At $227 per beneficiary per year Medicare can afford lots and and lots of physical therapy for these people.

At $37,543 per beneficiary per year Medicare can't afford much physical therapy.

The problem is this:

How can Medicare get physical therapy to those patients who need it most while preventing egregious cost outliers like in the first chart?

What to do?

Current legislation has the caps (and their exceptions process) in place until December 31st, 2009.

An alternative payment system is expected to replace the Medicare therapy cap within the next five years.

A pilot study will get underway in May 2009.

Current patients are facing hardships when their $1,810 physical therapy dollar limit is met.

Many physical therapists are uncomfortable appending the -kx modifier if they believe it raises the risk of a Medicare audit (it does).

Do the right thing

If your patient needs therapy and you can show they get better in a timely manner, do it.

If you are unsure or scared about how to document your findings then check out some of the free resources at www.BulletproofPT.com, your source for outpatient Medicare documentation and compliance knowledge.

Is Ultrasound Medically Necessary for Physical Therapy?

Do you use ultrasound on your patients?

Why?

How often or how much?

When do you stop ultrasound treatments?

What are the bases for your decisions?

Do you go with the flow?

Many physical therapists choose to use ultrasound for their patients.

Patients often demand ultrasound and physicians often request ultrasound.

Ultrasound is often criticized for its poor evidence base despite widespread anecdotal reports of it's benefit.

Show your work

Here'e the easy way to demonstrate medical necessity (need) for ultrasound.

Create a simple checklist or chart template that you or your staff could fill out every time you or they select ultrasound.

Copy the template or checklist and make it part of the initial evaluation.

Have extra copies ready for those patients who request ultrasound mid-way through their treatment.

Use the checklist to describe the findings that indicate ultrasound is necessary.

Findings: Inflammation

For example, pulsed ultrasound may be used as an anti-inflammatory modality.

This chart checklist, filled out at the initial evaluation, may support the medical necessity (need) for ultrasound when used as an anti-inflammatory modality.

You may also create a template to check off the findings that support ultrasound's thermal effects for scar tissue, etc.

(YES/NO)	CONDITION	Dimensions
	Swelling
	Redness
	Tenderness
	Palpable heat
	Loss of Function

One or more of these conditions present, with the dimensions noted, could provide a basis for ultrasound.

Properly filled out initially, and at subsequent intervals for Progress Notes, this chart checklist is a decision-making tool that can help the therapist understand when certain interventions are, and are not, indicated.

As a physical therapy clinical manager it is your responsibility to provide these tools to your clinical staff to ensure a Medicare compliant chart.

When it is so easy to do - why not?

Good for the patient, the therapist and the Medicare auditor

A Medicare auditor could look at this checklist to clearly and quickly see why the physical therapist had charged for sessions of ultrasound in the physical therapy plan of care.

Some therapists have used this pen-and paper tool to explain to their patients when ultrasound, a modality with a strong placebo effect, may no longer be indicated.

Bottom line, simple tools that demonstrate your skilled physical therapy decisions and show the need for your valuable treatments are essential in today's clinical environment.

For more free tools, templates and tips on physical therapy Medicare compliance go to www.BulletproofPT.com . 

Did error rates decline for physical therapists, too?

Modern Healthcare.com posted the news that the Medicare error rate declined in 2008 for fee-for-service providers.

"Improper payments to fee-for-service Medicare amounted to $10.4 billion in fiscal 2008, decreasing to a rate of 3.6% from 3.9% in 2007, the CMS reported."

FierceHealthcare.com reported that the lower error rate was due to the Medicare Recovery Audit Contractors (RAC).

You can read about the RAC impact on physical therapists here, here, and here.

AIS Health.com reports that the RACs will be delayed a few months (probably February 2009) while some of the government contractors work through a grievance process that is related to selection of RACs, not to health care providers.

As I've previously posted there is evidence to indicate that RACs preferentially targeted large, inpatient hospitals in the 'temporary' 3-year phase.

More restrictive audit rules for the permanent RACs increase the chance that the permanent RACs will continue to target large, institutional providers and leave small ones (eg: physical therapists) alone.

Can Physical Therapists go over the PT Cap with an X-Ray?

Does an X-ray demonstrate medical necessity for physical therapy?


...or does an axial CT myelogram?


These images are examples that have in common a clear pathology that many patients and physical therapists confuse with medical necessity for physical therapy.

Right now (November 17th 2008) I have several physical therapy patients who have exceeded their $1,810 Medicare benefit and are asking me for continued physical therapy services in my outpatient clinic.

Many of these patients have chronic conditions such as the following:

• degenerative spinal stenosis
  
• massive rotator cuff tears
  
• knee osteoarthritis

These conditions show up well on sophisticated imaging scans such as X-ray, CT scans and MRI.

These conditions often require extended courses of physical therapy or multiple episodes of physical therapy in the course of a calendar year.

In my clinic, the $1,810 Medicare cap is usually reached by 16-18 visits.

It would not be unusual for degenerative spinal stenosis to take 20 visits. I'm pretty sure my experience is typical.

Who needs PT?

For an exception to the Medicare cap the physical therapist would have to show three criteria:

• Need
  
• Progress
  
• Skill

Need is often shown with physical findings.

The above X-ray and CT myelogram show physical findings based on anatomy.

Physical therapists should show physical findings based on function.

Diagnosis: Process or Label?

An epiphany in own my practice has been the use of disablement models: most recently the International Classification of Function (ICF Model) that describes the link between Body Structure and Function and Activity Limitations.

The ICF classification framework is to physical therapists what the ICD-9 diagnostic labels are to physicians.

Note the ICF model describes any health condition - for instance, your patient with degenerative spinal stenosis who has 'run out' of Medicare physical therapy benefits but asks you to append the -KX modifier to continue their care.

What do you do?

Do you ask the doctor for another script?

Perhaps you consider using another diagnosis from the old 'diagnosis list' from 2006.

Don't.

The Therapy Cap

The purpose of the therapy cap is to cut costs without limiting patient access to necessary care.

There is a large POPTs in my town that automatically cuts off therapy to every patient approaching the $1,810 Medicare Cap - regardless of need or progress.

They perceive that, as a POPTs, they are in the Medicare audit crosshairs and they refuse to add 'risk' to their caseload by appending the -KX modifier.

They are limiting care to their patients.

The Caps Work

Data for this table comes from the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2) Task Order - Utilization Report.

Outpatient Physical Therapy
	2004	2006	Per cent change
Mean dollars paid per user	$864	$788.06	-8.8%
Mean dollars paid per episode	$748	$682	-8.9%
Standard deviation paid per episode	$1,047	$782	-25.4%

"The Balanced Budget Act of 1997 enacted financial limitations (therapy caps) on outpatient physical therapy (PT) and speech-language pathology (SLP) combined... In 2006 the Automatic Exceptions Process to the caps began, enacted by the Deficit Reduction Act of 2005." (OTAPS 2)

The result of the caps has been the observed decrease in per user and per episode dollars paid.

Read the full blog entry here.

Note that cost reductions occurred from 2004 to 2006.

There was no cap in 2004. The cap exceptions process began in 2006.

The Caps work - so, work with the Caps

Get better at showing need.

Show that your patients have Activity Limitations using a functional scale.

I recommend the OPTIMAL scale (free) or the AM-PAC (small $$).

Show Progress.

I've designed a neat pen-and-paper graph that easily and quickly shows functional progress over 1, 2 or 3 months.

No more discharges after 20 visits whether the patient is better or not.

Now, patients come back to me because they know I can 'go to bat' for them.

If they are getting better I can prove it.

Get a copy of the Functional Progress Graph here.

Make skilled decisions.

Use the ICF model to link impairments in Body Structure and Function with the measured Activity Limitations.

The link is your Physical Therapist's Diagnosis.

What do YOU need to go to bat for your patients?

Not fancy x-rays or 'alphabet soup' imaging.

Get better at describing your own skills using simple tools.

Get the free tools I've described in this post.

Also, get a free tutorial called Bulletproof PT to learn more.

Medicare RACs, snakes in the toilet and other urban myths

Snakes, swimming in your toilet bowl, are the sorts of things that keep eight year old boys awake at night.

Somehow, in 1976, word got around that it was possible for slithery snakes to sneak into sewer pipes and wind up in my bathroom.

I didn't sleep for weeks.

Also, I had, ahem,  other issues with snakes as a result.

Fortunately, snakes in sewer pipes turned out to be a baseless urban myth and no eight year old boys were harmed in the myth's dissemination.

Medicare RACs and physical therapists

Now, in 2008, physical therapist private practices are worried about Medicare Recovery Audit Contractors.

Maybe we have good reason.

Maybe we don't.

Recently, I was a 'fly-on-the-wall' at the Government Affairs meeting of the Private Practice Section of the American Physical Therapy Association.

Among the agenda items was a short discussion of Medicare RACs and their impact on physical therapist private practices.  The Medicare RACs were due to go nationwide in October 2008 but were delayed.

At this point, February 2009 is the expected kickoff date.

Many of the Government Affairs Committee members were from states other than the following...

• Florida
  
• California
  
• New York
  
• South Carolina
  
• Arizona
  
• Massachusetts
  

This list is the states selected in 2006 and 2007 as part of the RAC demonstration project.

Physical therapists in these states should be very familiar with the impact of the RACs.

One of the biggest 'hot buttons' among the PPS Government Affairs Committee members was the contingency fee structure used to pay the Medicare RACs.

The RAC contingency fee is paid based on...

"...detecting and collecting overpayments plus the fees paid for detecting and refunding underpayments."

Underpayments! What underpayments?

"As of March 27th 2008, RACs succeeded in correcting more than $1.03 billion in Medicare improper payments. Approximately 96 percent ($992.7 million) of the improper payments were overpayments collected from providers, while the remaining 4 percent ($37.8 million) were underpayments repaid to providers."

Regardless of whether you did or did not receive any refunded underpayments I believe the RAC contingency fee structure could be a very good thing for private practice physical therapists.

Contengency payments align risks faced by the provider and the auditor

Right now, if you are audited by a Medicare Administrative Contractor (MAC)  your claim is likely read by an employee or a consultant paid a salary or a flat rate.

If you appeal, your appeal is read by that same employee or consultant.

You must appeal to the third level, the Administrative Law Judge, before your appeal gets read by a fresh face.

Meanwhile, the auditor bears no risk.

The MAC auditor gets paid even if you prevail in your appeal.

The RAC auditor does not.

"In the RAC permanent program, CMS will require all RACs to refund any contingency fees they received if an overpayment determination is overturned at any level in the appeals process."

Why are RAC contingency payments good for private practice PTs?

Most of the overpayment determinations were made against inpatient hospitals.

Of the $992.7 million in overpayments approximately 85% were made to inpatient hospitals.

Overpayments Collected by Provider Type (in millions)

Skilled Nursing	$16.3	2%
Inpatient Rehab	$59.7	6%
Outpatient Hospital	$44.0	4%
Physician (& PT)	$19.9	2%
Ambulance/Lab/Other	$5.4	<1%
Durable Medical Equipment	$6.3	1%
Inpatient Hospital	$828.3	85%

"Because the Claim RACs were paid on a contingency fee basis, they establish their claim review strategies to focus on high-dollar improper payments, like inpatient hospital claims, which give then the highest return with regard to the expense of reviewing the claim and/or medical record.

CMS anticipates that the permanent RACs will adopt a similar strategy at first."

My experience in Florida since 2006 has been about $80 in overpayments over the four-year 'look back period' of the demonstration RAC project.

The permanent RAC is only allowed a three-year 'look back'.

My overpayments were due to charging multiple units of Traction or Electrical Stimulation (Supervised Modalities) to the same patient on the same day.

Now I know you can't do that.

There is some evidence that the Medicare RAC audit selection process differs from that of the Medicare MACs.

	% denials appealed	% appealed denials in provider's favor
MACs	4.0%	59.0%
RACs	14.0%	33.3%

The Medicare RACs appear to be more selective (eg: Inpatient Hospitals) thereby improving their percentage of provider unfavorable appeals.

Nevertheless, if you do get denied and you think you have a case, I recommend that you appeal.

Of the $19.9 million in overpayments paid by the 'Physician' category, the majority, 54%, were because of 'Excessive/Multiple Units".

I've made changes to my practice based on what I've learned in the last three years.

Get the RAC Evaluation Report here and get the facts.

If you are a small practice, like mine, you probably understand your business at the 'molecular level', that is, you do most of the work, you know most of your patients and you write or at least review most of your charts.

You are better positioned than Inpatient Hospitals to resist or defend a Medicare audit by a RAC or a MAC.

What about the Snakes?

John F. Kennedy said this...

"The enemy of the truth is not the lie, but the myth."

What you know is always less scary than what you don't know.

Now, I know that snakes won't get me when I go to the bathroom.

Now, I'm ready for the RACs as well.

Older physical therapy patients are worried

Every day I answer questions from older Americans about their physical therapy.

"Will I run out of Medicare physical therapy benefits?"

"What will happen to me - will I have to go into a nursing home?"

Medicare provides physical therapy treatment up to $1,810 in billed charges for the purpose of preventing a loss of independance in older Americans.

Americans living at home, cared for by their loved ones, consume fewer healthcare dollars than Americans living in institutions.

Medicare pays for much of the institutional care in the United States.

Sarah

Today, I treated Sarah, an 86-year old lady with arthritis.  

Sarah is legally blind and cannot walk far because of pain in her back and legs due to a condition called spinal stenosis.

Sarah's husband died a few years ago and now she is alone. 

Sarah can clean her home and care for herself with minor accomodations - she rides the handy bus to church, groceries and physical therapy.  

She doesn't go out much but she lives in a trailer park where neighbors are close by.

But, Sarah is not far from needing more help.

She has been in physical therapy for her spinal stenosis for a month now and we have gotten her back to walking and single-stair climbing (we live in Florida). 

Sarah is much more comfortablenow moving around and doing light lifting.

Friday, November 7th is Sarah's projected discharge date and she is worried that physical therapy will not continue.

She is afraid that she will decline without therapy and require more help to live alone.

Soon, she believes, she will need to move out of her trailer and into a nursing home.

Sarah believes physical therapy can help prevent this decline.

So do I.

Medicare depends on me to prevent Sarah from losing her independance and going to live in a nursing home.  But, for that, I have to make decisions that expose me to the threat of a Medicare audit if it is determined that I gave Sarah 'too much' physical therapy.

What do I do?

I must show that I can help Sarah, that Sarah needs my help and that only a physical therapist, such as I, could help Sarah.

For that I need help.  I need two tools.  Both are free tools.

The first tool is the OPTIMAL.

I use the OPTIMAL to show that Sarah needs physical therapy.

The OPTIMAL also shows that Sarah can now walk further and move around better than she did one month ago.  It shows she makes progress in physcal therapy.

But, I also need one more tool.  I need to append a '-kx modifier' to my physical therapy charges that I send to Medicare.  

I want to show any Medicare auditor that my decision to append that modifier is based on results, not just a one-time event or measurement.

So, I graph my OPTIMAL scores.

Here is the graph template.

What happens to Sarah?

Friday I take my follow-up measurements.  

Sarah's need and progress is evident.

My skill and decisions are well-documented with the graph template.

This time, I think she will qualify for the extra month of physical therapy.

Physical Therapists use the ABN too much

Are you using the Medicare Advance Beneficiary Notice (ABN) too much?

How much is too much?

Most physical therapists' practices, in my opinion, would need infrequent use of the ABN.

I often use the the -KX but I seldom use the ABN.

How about an example?

I usually hit the physical therapy cap in 16 visits.

But now, in November 2008, I have some patients coming back to see me with multiple conditions.

They need to know if their physical therapy is a Medicare covered benefit.

So, I face the same problem you face.

I think that I might be able to help you.

What should the physical therapist do?

The routine use of the Advance Beneficiary Notice (ABN) with EVERY
patient who has $1,810 in billed charges may be inconsistent with the
design of the ABN.

With the ABN, you are saying to the patient (and Medicare):

"These services are not a Medicare covered benefit".

For example, maintenance exercise is not a Medicare benefit.

However, PT services above the annual cap ARE a Medicare benefit, if
the patient qualifies for the cap (-kx) exception.

You are the only professional in the position to determine if the patient
qualifies for the benefit.

You make your determination based on three criteria:

1) Need

2) Progress

3) Skill

In other words, does the patient need your services, can you get them
better and can you demonstrate your clinical decision-making was
necessary for their care?

Now, in November 2008, I have many patients coming back to me who have
exceeded their cap.

They may have had their rotator cuff done in February and now they
have hip pain in November.

Note: you cannot use the list of diagnoses from 2006 as the sole basis
for an automatic exception.

I usually hit the cap in 16-18 visits so patient with complex
conditions or multiple conditions will often exceed $1,810 over the
full year.

I face the same problem you face - how do I get my patients treated
and comply with Medicare rules?

Medicare doesn't know how much better patients get with PT, how bad
they were to start with or what their outcomes are.

So, I figured out a way to show Medicare.

I also made it simple for clinical physical therapists.

I designed a graph that plots all 2008 OPTIMAL functional scores on
one page. That way, when the patient comes back in October I have
their prior level of function.

I can use the graph to show a decline in function in the absence of
skilled physical therapy - that demonstrates need (medical necessity
for physical therapy).

The graph can also show the improvement from the last session of
therapy in February (expected improvement in a reasonable time frame).

Skilled decision-making is, I believe, self-evident to anyone who can
figure out the PT cap exceptions process. If not, then I have also
designed a note-writing format for my charts that prompts skilled
decisions at each visit.

Every billed charge needs to be skilled, whether you have hit the cap
or not.

Finally, the graph is simple to use, even for those of us who still
use pen and paper charts.

You can get the graph, for free, at www.BulletproofPT.com

Medicare wants you to treat patients who demonstrate need, who get
will get better and who can't do it without your skills.

The ABN is not your answer.

Try the graph and let me know what you think.

Dororthy got kicked out of Physical Therapy today

Dorothy got kicked out of physical therapy today.

Dorothy is one of my patients.

She is almost 80-years old, still lives at home with her husband and tries to walk every day.

She lives year-round here in Florida in the same town she grew up in.

Dorothy has a condition, called degenerative spinal stenosis, that causes her back to hurt when she walks more than one city block.

Dorothy has been to my physical therapy clinic for treatment of her stenosis three times in 2008: January, May and now in October.

Each time she has come to see me we have been able to help her walk better and maintain her independence.

Only now she has used up her Medicare physical therapy benefit.

I say she got 'kicked out' because that's how I felt when I told Dorothy that Medicare would likely no longer pay for her care.

Sure, Dorothy had the option to pay cash but, at $100 per treatment session, that is not much of an option.

I felt like crap when I walked her to the door and gave her a hug and said goodbye.

She was much kinder to me than I was to myself.

Dorothy said she understood the situation and that she would do her exercises at home.

What will happen to Dorothy?

The reality is that that Dorothy will begin a functional decline without skilled physical therapy.

How do I know?

I measured it.

In January, May and October I took functional measurements of Dorothy with a Medicare-recommended tool called the OPTIMAL scale.

Each time Dorothy came to therapy we re-measured her performance on the scale. Each session of physical therapy showed improved performance on the OPTIMAL.

Each time Dorothy stopped physical therapy her performance declined. The treatment effect was not persistent.

Dorothy's muscles around her spine were too weak to support her aged bones and discs.

Dorothy stopped walking because walking hurt.

She couldn't clean her house because vacuuming hurt her back and her husband had to do it.

She had to depend on her husband more and more and soon his back began to hurt.

At one point, I had both Dorothy and her husband in therapy.

The husband soon got better but Dorothy noticed that she was unable to push herself at home sufficiently to exercise her muscles. Also, she didn't have the specialized equipment, like spinal traction and exercise equipment, that we had in therapy.

Because of her age and her aptitude she was not safe working out in a self-pay gym setting.

Even a personal trainer was not a safe option for Dorothy.

What will I do?

If Dorothy calls me again in 2008, asking for help, I will see her for an evaluation.

Physical therapy evaluations are not subject to the cap.

Technically, you should not even have to append the -kx modifier to a 97001 CPT code for a patient over the cap since you need to evaluate them first to see if they qualify for the automatic exceptions to the cap.

In your evaluation you should measure impairments in body structure and function as well as activity limitations.

Link the impairments to activity limitations with your physical therapy diagnosis.

I measure activity limitations with the OPTIMAL scale.

Dorothy's OPTIMAL scale was graphed for 2008.

Here is what the graph looked like and how it provided the justification for going over her annual $1,810 per beneficiary, 'Uniform Dollar Limitation' (cap).



If you need to learn about 'justification statements' or 'the exceptions process' or even 'medical necessity for physical therapy' you can get free information at Bulletproof Physical Therapy Charts.

Give your patients all the physical therapy they need.

Unless they're ready, don't kick them out.

Arnie Falls Down a Lot and He Needs Physical Therapy

Arnie falls down a lot and he needs physical therapy.

Arnie is a 74 year old bookkeeper, living with his wife Betty in a trailer in Florida.

He lives on a fixed income - social security and some retirement income. He gets his health care from Medicare.

He has no pension since he lost his good job in the recession of 1990 and he has had to work odd jobs for the past 15 years.

Now, Arnie is weak in the legs and his balance is bad.

He fell down six times in two weeks in August and asked his doctor for a referral to physical therapy.

Physical therapy has a falls prevention program of strengthening, balance, flexibility and falls awareness training that has been shown to help seniors prevent falls and increase mobility.

But then, Arnie fell on a rain-slick driveway at night and landed on his shoulder - he ended up tearing his rotator cuff.

Arnie had used up 12 of his physical therapy visits and Medicare only allowed him about four more visits.

In America today, there are many people like Arnie - denied their Medicare physical therapy even though they clearly need help.

Today is October 25th, 2008 and every Medicare beneficiary in America has about $1,810 in physical therapy benefits for the entire year.

Unfortunately, by now many have used some or all of their benefits and could face a difficult and painful recovery if Medicare wont pay for extra physical therapy.

Fortunately, there is a solution.

Many therapists (and doctors) are unaware (or afraid) to use this solution.

The Exceptions Process

The $1,810 physical therapy Medicare cap has an exceptions process based on need and expected patient progress.

If I can show that Arnie needs extra therapy (he does) and that I can expect to get his shoulder better and prevent future falls, then he can have his extra therapy.

Therein lies the rub.

How to make the case for Arnie?

The need is easy.

Arnie is a train wreck, poor guy.

I measure his strength, flexibility and range-of-motion, as well as activity limitations using standardized test scores.

Future expected benefit is the hard part.

Many physical therapists don't know how to show expected future benefit from physical therapy.

You need to show a positive trend in your standardized test scores.

You should then graph your trend line to provide an easy visual reference for anybody who questions your decision or audits your chart.

Create a graph template that you can fill in with one, two or three months worth of test scores.

When you connect the dots the trend line should be going up - this indicates progress.

Download this free template at www.BulletproofPT.com.



Remember to modify the template to fit the needs of your physical therapy facility.

Are you physical therapy 'Audit Bait'?

Are you physical therapy audit bait?

How can you tell?

Well, are you an 'outlier' - that is, a high cost user of Medicare physical therapy services?

Physical therapists in private practice should look at their physical therapy patients to see how many have exceeded the physical therapy caps and by how much.

Also, see how many patients have gone over the average payment for a Medicare physical therapy episode.

Data Drilling

Medicare auditors will look first at billing outliers - those episode charges that exceed some threshold, say two standard deviations above the average (mean).

What is the mean and what is one standard deviation?

Data for this table comes from the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2) Task Order - Utilization Report.

Outpatient Physical Therapy
	2004	2006	Per cent change
Mean dollars paid per user	$864	$788.06	-8.8%
Mean dollars paid per episode	$748	$682	-8.9%
Standard deviation paid per episode	$1,047	$782	-25.4%

"The Balanced Budget Act of 1997 enacted financial limitations (therapy caps) on outpatient physical therapy (PT) and speech-language pathology (SLP) combined... In 2006 the Automatic Exceptions Process to the caps began, enacted by the Deficit Reduction Act of 2005."

The result of the caps has been the observed decrease in per user and per episode dollars paid.

Note that the standard deviation also decreased - substantially.

One of the take home messages from this chart is that the caps work for cost savings.

From the OTAPS 2 report...

"... the payment reductions were incurred by providers tapering services for higher cost users that tended to skew mean payments upwards."

Do the caps restrict access to physical therapy services by Medicare beneficiaries?

Beneficiary Access

"The utilization analysis in this report clearly demonstrates that the outpatient therapy caps, as implemented in CY 1996 with the exceptions process had little or no impact on beneficiary access to outpatient therapy services. This is in sharp contrast to CY 1999 when the caps were implemented without an exceptions process."

So, the caps decrease costs by decreasing therapy services to 'higher cost users' - that is outliers.

Finally, the exceptions process seems to work to preserve access for those beneficiaries (patients) who need physical therapy the most.

What do you do if you are an outlier?

Some physical therapists may be legitimate outliers.

In other words, their patients need physical therapy services more intensively or more frequently than the general population.

In my area of the country, I could be a geographic outlier because some local health care providers (doctors and physical therapists) have told their patients that the Medicare cap is a 'hard cap' that cannot be exceeded.

If I apply the cap based on medical necessity then my average charges will be higher than my local peers.

Some physical therapists are afraid to append the -kx modifier and exceed the cap.

What do you do?

Show your work

Remember in high school you could get partial credit on a math test if you showed how you got to the final answer? Well, Medicare is like that.

You can be an outlier on costs if you show your work.

Show that your patients need physical therapy and that they qualify for the -kx modifier on your charge slip (medical necessity).

Show that you are getting your patient better (expected improvement in a reasonable time frame).

Show that your services are skilled (physical therapist decisions and physical therapist assistant judgments).

If you are not sure how do some or all of these Medicare criteria go and download some of the free resources at www.BulletproofPT.com.

Do physical therapists treat pain?

I took this table (my formatting) from Towards a Common Language for Functioning, Disability and Health to illustrate the role physical therapy plays in the ICF framework.

Note that physical therapy is an intervention at the Activity Limitation level of disability.

Most physical therapists would agree that our specific techniques are addressed towards the Impairment (strength, pain, ROM, swelling, etc.) but that our expected outcomes are at the level of the Activity Limitation.

How the ICF levels of disability are linked to three
different levels of intervention

Intervention
Prevention
Health
Condition
Medical treatment
Medical care
Medication
Health promotion
Nutrition
Immunization
Impairment
Medical treatment
Medical care
Medication
Surgery
Prevention of the
development of
further activity
limitations
Activity
Limitation
Assistive devices
Personal assistance
Rehabilitation
therapy
Preventive
rehabilitation
Prevention of the
development of
participation
restrictions
Participation
Restrictions
Accommodations
Public education
Anti-discrimination
law
Universal design
Environmental change
Employment strategies
Accessible services
Universal design
Lobbying for change

There are many ways to assess activity limitations but one of the best clinical ways to assess them is to ask your patient...

"How have you gotten better?"

Then score the patients' response on a 5-point Likert scale: 1 = no difficulty, 5 = cannot do.

Record serial measurements of their activity as you progress them through their physical therapy plan of care.

Remember, pain is an impairment level characteristic.

Physical therapy primarily treats activity limitations.

Orthopedic surgeon limits patient access to physical therapy

It's October 11th and Medicare patients are losing access to their physical therapy services.

Yesterday, I saw one of my 'snowbirds'. She is 79 years old and she spends the summer in Maine and the winter in Florida (I live in Florida).

She came in to see me in January and had rehab on her rotator cuff. Now, she is back because she fell on the golf course and injured her knee.

Her orthopedic surgeon saw her after the fall gave her a cortisone shot and four visits to therapy.

Four visits?

The surgeon didn't give her more therapy in case she needed surgery.

He explained didn't want to 'use up' her therapy by hitting the Medicare cap. He felt she would need more therapy after surgery.

The cap is a spending limit that Medicare applies to every beneficiary. This year the cap limits the beneficiary to $1,810 in billed physical therapy.

Typical physical therapy billed charges use up the cap in 16-20 visits.

Patients are coming to me now who have used up their benefit in July, or May or whenever.

What the surgeon didn't know (or didn't tell) was that the physical therapist can apply for an exception in special circumstances.

The exception is based on three simple things:

• Patient need
• Patient progress
• Physical therapist decision-making

In other words, this lady had just fallen down, she was at increased risk for future falls and she was not getting her physical therapy based on her surgeons' interpretation of the Exceptions Process to the Medicare Cap.

With all due respect, most surgeons should just stick to surgery.

Physical therapists in outpatient, non-hospital clinics can examine their patients, case-by-case, to see if the patient has characteristics that would qualify for the exception.

The fact that this surgeon was the owner of one of the largest non-hospital physical therapy clinics in the state of Florida and a direct competitor of mine may have had something to do with his 'interpretation'.

I don't know.

Medicare Fraud Strike Force Indicts Eight in Miami

So far this and other Medicare actions in the South Florida area do not appear to have involved physical therapists.

The Medicare Fraud Strike Force arrested eight individuals in October 2008, including two doctors, charging them with conspiracy and fraud in a scheme to bill Medicare for HIV infusion treatments that were never performed.

Similar schemes involving compounding pharmacies in 2007 cost the Medicare program $20 million dollars.

In May 2007 a Miami medical billing company was convicted of fraudulently collecting $56 million from Medicare.

Medicare payments to home health agencies in Miami have increased 1300% since 2003.

Medicare is...

"focusing on home health agencies that send nurses to give homebound diabetics insulin injections. Some patients are neither homebound nor unable to give themselves the injections...Some don't even have diabetes."

So, how does this affect physical therapists?

All health care providers are suspect when these kinds of abuses occur.

Medicare must enact tougher controls to manage the system.

Better control of 'outlier' payments is first on Medicare's list.

From the October 10, 2008 USA Today -

"Randall Culp, an FBI agent who oversees a team that investigates Medicare fraud, says Medicare should move faster to revoke Medicare status for questionable home health agencies and crack down on outlier payment abuses."

If you are a legitimate outlier, for instance a manual physical therapist who charges a lot of Manual Therapy (CPT 97140) you need to make sure that your notes support your billed charges.

You need to show...

• Medical necessity for physical therapy (measurable, treatable findings)
• Expected improvement in a reasonable time frame (progress)
• Skilled physical therapy (decisions)

A legitimate outlier would have a patient population that requires above-average amounts of a particular intervention, for instance chronic low back pain.

Documented pain diagrams or patient-reported functional scales, such as the OPTIMAL can help demonstrate medical necessity for physical therapy for this patient population.

Validated outcomes measure such as OPTIMAL or AM-PAC can show progress.

Skilled therapy is demonstrated by your decisions.

Get training for improved physical therapy decision making at BulletproofPT.com.

Outpatient physical therapists under scrutiny by Office of the Inspector General

The OIG 2009 Work Plan has several areas that address outpatient physical therapists directly.

• Outpatient Physical Therapy Services Provided by Independent Therapists

"We will review outpatient physical therapy services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 220.3, contains documentation requirements for therapy services. Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with Federal requirements.
(OAS; W-00-09-35220; various reviews; expected issue date: FY 2009; new start)"

• Physicians’ Medicare Services Performed by Nonphysicians

"We will review services physicians bill to Medicare but do not perform personally. Such services, called “incident to,” are typically performed by nonphysician staff members in physicians’ offices. The Social Security Act, § 18610(s)(2)(A), provides for Medicare coverage of services and supplies performed “incident to” the professional services of a physician. However, these services may be vulnerable to overutilization or put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. We will
FY 2009 OIG Work Plan 15 Centers for Medicare and Medicaid Services
examine the qualifications of nonphysician staff that perform “incident to” services and assess whether these qualifications are consistent with professionally recognized standards of care.
(OEI; 09-06-00430; expected issue date: FY 2009; work in progress)"

Outpatient physical therapists with high, unexplained utilization rates will have to show good documentation for their charges.

Physician-owned physical therapists will also have to demonstrate the following:

• Medical necessity for physical therapy (treatable findings)
• Expectation of significant improvement in a reasonable time frame (progress)
• Skilled physical therapy (PT decisions or PTA clinical judgment)

For a step-by-step program that a PT manager can implement without becoming a 'Medicare expert' go to BulletproofPT.com to protect yourself and to sleep well.

Use the ICF Core Set to diagnose lower back pain

Sooner or later physical therapists will be required by Medicare and commercial insurance companies to identify the impairments we treat by using the ICF Core Set.

Might as well start now.

Basically, you do it now when you select an ICD-9 code for your patient when you bill American Medicare.

For instance, 724.04 is lower back and leg pain due to spondylotic changes. While accurate, in many cases, this pathologic diagnosis is also not very informative for PT decision-making.

Like, what body part is stiff?

Are the hips affected?

Should I manipulate the patient's lumbar spine?

Which muscles need strengthening?

While the ICF Core Set is no substitute for clinical training, experience and a sharp mind it is a step in the right direction of getting physical therapists away from thinking about pathology and thinking about function.

Link the patients' activity limitations to their impairments in body structure and function.

Your assessment of the link is your physical therapy diagnosis.

Predictive physical therapy: can questionnaires aide prognosis?

There is a new age of accountability (financial, regulatory and otherwise) in physical therapy.

Some examples...

Physical therapists are being asked to work and get paid based on their productivity rather than a fixed salary.

Medicare requires physical therapists to 'diagnose' their patients using objective, public-domain tools, like the OPTIMAL scale.

Now, physical therapists can predict whether patients will adhere to physical therapy after spine surgery. The test is called the Patient Activation Measure (PAM) questionnaire.

"Essentially, the test places patients on a continuum of activation ranging from those who don't see an active role on their part as necessary to those who are highly motivated to take an active role in their own health care." said lead author Richard L. Skolasky, Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

My professor in physical therapy school once told me that questionnaire data was 'soft' and that we needed 'real numbers' for good decision-making in physical therapy. In 1992, my professor called questionnaire data 'subjective' data.

Well, that was 1992 and this is 2008.

In 2008 and beyond, more of our physical therapy data will come from questionnaires. The good news is this... questionnaire data is good data.

The test that is destined to replace the OPTIMAL scale is the Activity Measure for Post Acute Care (AM-PAC). The AM-PAC produces good data.

Data is going to be necessary for physical therapists to demonstrate value to payers.

In 2006, the single largest purchaser of health care in the world, US Medicare, spent $3.06 billion on physical therapy.

Questionnaires can give us good data.

Good data can improve physical therapy accountability, diagnosis and prognosis.

How to use the International Classification of Function

The value of any model is the ease with which people can adapt the model to their own ends and needs.

The International Classification of Functioning is a simple, powerful model that serves the needs of many stakeholders.

Physical therapist can use the ICF Browser to classify and diagnose their patients.

Physical therapy educators can use the ICF framework to train PT students to treat and measure function.

Researchers can use the ICF framework to measure outcomes of physical therapy interventions.

Government policymakers can use the ICF codes to collect, understand and manipulate data on the consequences of health conditions.

Professional societies, such as the APTA, can use the ICF to more accurately align their role in the health care system.

Non-governmental organizations, like the World Health Organization, can use the ICF to guide disability management.

Finally, for my purposes, the ICF is a tool that I can use to to help my physical therapists and physical therapist assistant staff write Bulletproof Notes for Medicare compliance in my outpatient physical therapy clinic.

United States physical therapists not alone in health care crisis

Physicians, and possibly physical therapists judging from the 'sports medicine' reference, in Canada are innovating their way out of another Medicare mess.

Private businessmen in Canada have opened several private-pay clinics in Calgary that treat patients with services that Medicare does not provide.

"The new Calgary clinic, the company's second location, will offer an "elite program" of medical care for its members, including a full health assessment and a preventative health plan."

The clinics are opposed by the Friends of Medicare, a pro-consumer organization that calls the expensive, private arrangements 'queue jumping'.

A queue is a line that refers to the way Canadians (and British) ration their health care services.

Canada rations health care according to age. Older folks go to the back of the 'queue' while younger folks with jobs get treated first.

The United States rations health care by wealth.

Wealthier people get treated first. In some areas of the United States Medicare is the best and fastest third-party payer which means that younger people with jobs are frequently treated last.

Arguments against this answer to Canadian Medicare?

"It sucks," said Noreen Branagh. "I can't afford the $4,000, and there are no family doctors in Calgary."

Arguments for this answer to Canadian Medicare?

"Primary care is in a crisis. At least I've gotten up and done something about it." says Don Copeman, the Vancouver businessman who founded the clinic.

Physical therapists: Use the ICF Browser to make your diagnosis

Wow!

The new ICF Browser is an exciting tool. I'm not kidding.

The new International Classification of Functioning (ICF) Browser has the capability to specify exactly what physical therapists do and how we work on patients.

Example:

Today I evaluated a 50-year old female office worker before lunch. She had tried to lift a heavy piece of furniture five days ago and developed sudden-onset right lower back pain.

She presented today with a lateral shift in standing, positive right sciatic tension test, good (>35 degrees) hip external rotation, negative Gower's sign and a stiff back (P/A).

She was in no apparent distress (low fear-avoidance) and had no prior episodes of lateral shift.

Should I classify her in a manipulation or a stabilization group? Are the two groups mutually exclusive?

Anyway, I have started using the new ICF Browser to classify my patients according to my findings.

I have begun to avoid diagnostic labels altogether.

The physical therapy diagnostic process has more potential to inform physical therapist decision-making than does classification with diagnostic labels.

Here is my decision-making process and the ICF codes that go with my findings:

Activities - code	Body Functions - code	Body Structures - code
Difficulty Lying - d4150	Pain in leg - b28015	Lumbar vertebral column - s76002
Difficulty rolling - d4201	Stability of several joints - b7151
	Tone of trunk muscles- b7355

I will primarily address the loss of function: impairments in strength, endurance and mobility (ROM) in outpatient physical therapy.

Note how the link between the measured activity limitation is the physical therapist's diagnosis. Treat the findings and don't worry about the label.

Re-measure the findings (activity limitations and impairments) to assess success.

Every physical therapist should be comfortable making a functional diagnosis.

Our patients deserve one.

Physical Therapy Group Code is not a 'Red Flag'

Physical therapists can get in trouble when they don't bill the PT group code.

I've posted on this before.

I've indicated that physical therapists that do not use the group code (CPT 97150) may be billing one-on-one codes for treatment that probably meets the definition of group physical therapy.

That is called 'upcoding'.

The group code accurately reflects clinical behavior in a typical physical therapy clinic. That is, occasionally, you get busy and you have to supervise more than one patient at a time.

Physical therapists often 'dovetail' their patients - treat on a half-hour schedule but see each individual patient for, perhaps, one hour.

This means that, on average, the patient receives 2 units of 'one-on-one' constant attendance procedures. The Medicare website provides examples of 'constant attendance' procedures as follows:

"In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients. Examples include:

1. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97542);
2. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);
3. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) and (b) above -- (CPT codes 97032- 97542). For example: any CPT code for a therapeutic procedure (eg. 97116-gait training) with any attended modality CPT code (eg. 97035-ultrasound);
4. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 - 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);
5. Any CPT code for modalities requiring constant attendance (CPT codes 97032 - 97039) with the group therapy CPT code (97150). For example: group therapy (97150) with ultrasound (97035);
6. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)"

The therapist can also bill the physical therapy group code (CPT 97150) if their clinical behavior meets this definition:

"Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy, 97150 (untimed)."

The physical therapy clinic is question did not, apparently, use the group code at all. This description is a summary of their reported fraud...

"Federal authorities said therapists routinely provided services to multiple patients at the same time, but billed government programs as if the therapists were providing one-on-one care."

Learn to use the group code.

To learn more about physical therapy Medicare compliance get free downloads at BulletproofPT.com .