"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

Wednesday, February 27, 2008

PT Clinical Management

I got this e-mail from one of my clinic managers regarding our latest update to the Physician Re-certification Note (which, for Medicare purposes doubles as our Progress Note).

Eric and I regularly bounce ideas off of one another in order to improve the compliance of our Medicare treatments.

The point of this post is to emphasize that, in small PT practices, Medicare compliance is a two-way street. Everyone needs to be on board. Everyone needs to be committed.

Here is the e-mail exchange.

Real Time Clinical Management

From: Eric
Sent: Wednesday, February 27, 2008 6:23 PM
To: Tim Richardson PT
Subject: Re-certification note revision


I see no problem with adding the Justification Statement for Physical Therapy. I don’t need the reference for this, but some examples sure would help.

Also, would you consider removing the goals met line? I could use an extra Impairment line and I will usually write (Met) on the line over (Goal) instead of checking off the box.



Great question.

Once you've demonstrated Medical Necessity (in the POC) there is no further need in the daily Treatment Encounter notes to do so.

However, if you elect to continue the patient a 2nd 30-day period you should show, in the Progress Note, both Medical Necessity and the Expectation of Significant Improvement in a Predictable Timeframe (30 days).

If, for whatever reason, either of these criteria are not immediately obvious from the measurements, the OPTIMAL, the disability statements or from the Treatment Encounter Notes then you should, in the plainest language possible, state so in the Justification Statement.

For Example:

"Continue PT TIW x 4 weeks b/c diabetic frozen shoulder is taking longer than a 'regular' frozen shoulder."


"Continue PT TIW x 4 weeks. Patient motivated and ready to get back to PT after d/c from hospital for chemo"


"Continue PT TIW x 4 weeks. New Goals as follows..."
(note: new goals should progress patient to a higher level of function as demonstrated by serial (bi-monthly) OPTIMAL scale)


"All LTG met. Continue PT BIW x 2 weeks for instruction in maintenance program at fitness center"


"Continue PT TIW x 4 weeks. Patient very old (89 yo) and debilitated (100#) and Ther Ex is very slow."

Whatever, as long as the language makes sense and can be backed with measurements.

Remember, measurements and the interpretation of measurements is how you demonstrate Skilled Therapy (the only requirement for the daily Treatment Encounter Note).

Remember, once the patient hits the cap ($1,810.00 for 2008) there is the Automatic Exception based on Medical Necessity.

Don't use the diagnosis list only as your basis for an exception.

Remember your list of complexities and conditions that contribute to the Automatic Exception.

Bottom line, let the needs of your patient drive your therapy recommendations.

Call me if you have any questions.

I will ask Greg if he wants the 'Goals Met' sequence to be deleted.


Sunday, February 24, 2008

How to write a Medicare Progress Note

Watch this video to see an example of a Medicare Progress Note that fufills the minimum requirements as set forth in Transmittal 63 (Medicare Benefits Policy Manual).

In the video, I talk about medical necessity for physical therapy, justification statements in the plan of care and in subsequent progress notes, the re-certification note and more.

Finally, I tie it all together with the Physical Therapy Diagnosis.

Sunday, February 17, 2008

Three Obstacles to Physical Therapy Diagnosis

It occurred to me that there are many reasons why physical therapists might not want to or can't routinely diagnose their patients. Here are three reasons that seem to be the most obvious.

1. Physical Therapy Diagnosis is too hard.

Physical therapists already provide implicit diagnoses.

It’s high time physical therapists develop some backbone and put a ‘Physical Therapy Diagnosis’ in the written Plan of Care to the physician, for example the following diagnosis is routine in my clinic.

“Functional limitation in overhead lifting due to loss of shoulder external rotator muscle strength” (measurement in the body of the plan)

The diagnosis implies the treatment (strengthening) which is also written in the Plan of Care.

2. Physicians don’t want a Physical Therapy Diagnosis.

A popular physical therapy management consultant advises his clients (PTs) to not diagnose patients because physicians will be upset and referrals will decrease.


If you want referrals ‘out the wazoo’ then you should act like the highly trained, educated professional that you are.

Physical therapists who take pride in their work, who diagnose functional deficits and who treat impairments in ROM and strength will become recognized as high-quality musculo-skeletal care providers.

Physicians ultimately want what is best for their patients and will tend to refer to those physical therapists who get good results.

3. Physical therapists aren’t trained in diagnosis

Diagnosis is a logical process that many trained professionals use to simplify complex sets of information and to standardize the workflow.

Physical therapists are trained in physical therapy.

Diagnosis is the result of systematically applying your training, education, experience and observational skills to your patients on a daily basis.

Each patient is unique but their conditions are rather routine.

· abdominal muscle weakness
· spinal instability
· hip joint stiffness
· postural syndrome
· shoulder joint stiffness
· rotator cuff weakness
· scapular dyskinesia
· knee extensor weakness

These are some of the conditions that every orthopedic physical therapist sees on a daily basis.

Each of these conditions is linked to a finite set of functional limitations (as described in the OPTIMAL scale).

Each patient deserves their own diagnosis.

Saturday, February 9, 2008

The Orthopedic Surgeon Test

The Orthopedic Surgeon Test is a tongue-in-cheek name for a pragmatic approach to physical therapy clinical decision-making.

Whenever a physical therapist makes a clinical decision the test is to ask yourself the following question:

"What would the orthopedic surgeon think about this decision?"

So, if the physical therapist is asked a common clinical question like, for instance, the following:

"Do I put heat or ice on this hot, red, swollen and tender body part?"

Then, when you make the clinical decision to advise the patient to put ice on their inflamed body part you would certainly pass the Orthopedic Surgeon Test.

Physical therapists should extend this level of critical scrutiny to every clinical decision.

Perhaps I put too much pressure on or give too much credit to orthopedic surgeons in naming this test for them.

My assumption is that since their decisions ultimately direct the care for many of our orthopedic patients then they should get the glory (or the blame).

Orthopedic surgeons commonly base their decisions on independent measurements like x-rays. I use the term independent rather than 'objective'. Independent measurements imply that their interpretation will be the same for every observer.

Any decision that is based on a measurement will withstand scrutiny.

Physical therapists should also base their decisions on measurements.

Measurement eliminates argument.

A good example of clinical decision-making happened yesterday in the clinic. A patient asked me for a stretching exercise for her left hamstring - she said it was 'tight'.

This patient had a two-year old L4-5 microdiscectomy, complete motor palsy of the Flexor Hallucis and Digitorum Longii muscles (S1), sensory loss along the entire S1 dermatome and hamstring weakness (S1).

Additionally, her supine Straight Leg Raise (SLR) test measurements were the folowing:

Left 88 degrees
Right 85 degrees.

The video demonstration of this measurement technique can be found here.

Her left hamstring was longer than the right.

Perhaps because the hamstring muscle was weak she percieved 'tightness' and felt the urge to stretch.

Measurement, however, revealed that the hamstring was not 'tight'. The hamstring was not short and did not need stretching.

I re-measured the SLR and explained my findings to the patient. I advised her against stretching the hamstring muscle.

This young lady has a physical therapy plan of care that emphasizes stabilization training and avoidance of endrange movements like flexion and extension. Her understanding of physical therapy had led her to believe that stretching was a part of every patient treatment and thus would be a part of her treatment.

In fact, the measurements revealed that her mobility charcteristics could be labeled 'hypermobility' and her clinical presentation (which is more detailed than I have presented here) could be labeled as 'lumbar instability'.

Stretching, for this young lady, could be hazardous.

Based on my measurements I was comfortable in standing my ground and recommending against the patients stated desires. I did not provide her with the treatment that she thought she wanted.

If the orthopedic surgeon called and asked for hamstring stretching I believe I would make the same recommendations.

My clinical decision passed the Orthopedic Surgeon Test.

Sunday, February 3, 2008

“Medicare changes every year”

In 2006, Medicare issued three new transmissions that altered the technical language of the Benefit Policy Manual.

In 2007 Medicare issued no new transmissions that altered the technical language of the Benefits Policy Manual.

In 2008 there will likely be one transmittal in February that will alter the language of the Benefits Policy Manual. The alteration mainly deals with the new ninety (90) day re-certification period.

Nevertheless, the myth among many physical therapists and physical therapist assistants is that Medicare changes every year and, as a result, there is no way to understand or to predict the seemingly random and haphazard changes in the rules.

I've noticed this belief among physical therapy students and physical therapy educators. There appears to be a reluctance to instruct students in the basic requirements to treat Medicare patients.

These requirements are the folowing:

    Demonstrate the Medical Necessity of Physical Therapy

    Demonstrate that you expect the patient to recover significant function in a reasonable time frame.

    Demonstrate skilled physical therapy services.

If new graduate physical therapists and educators focus instead on the process of physical therapy diagnosis and on the needs of the patient then the technical requirements for treating Medicare patients may seem less burdensome.

The patients’ needs never change

While the technical requirements of treating the Medicare beneficiary do change and these changes seem to have less to do with physical therapists’ job demands and more to do with policy or political machinations at the national level it is important to remember that the patients’ needs never change.

The premise of the SIMPLE system is physical therapy diagnosis leads to good documentation and that ongoing assessment requires a written record of prior measurements.

Goal setting and the selection of interventions is a logical, predictable process predicated on the findings in the evaluation.

Physical therapy diagnosis is a process, not an event.

The initial diagnosis is often based on incomplete data that may be refined or changed by the time the discharge note is written. The diagnosis in the discharge note may be the same or it may be entirely different from the initial diagnosis.

When physical therapists understand that Medicare pays for (and demands documentation that demonstrates) the ongoing assessment and ultimate diagnosis of the physical therapist then the technical changes are less relevant to the process.

The process never changes.

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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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