Is Physical Therapy Valuable?

Physical therapists think that Medicare is run by bureaucrats (it is) but Medicare physical therapy policy is also set by bureaucrats (it isn't).

Years ago, I graduated from the University of Florida Physical Therapy Program with a Bachelors Degree in Health Science. I was trained in orthopedics and neurology. I was not trained in Medicare.

To get information from Medicare, in 1992, you had to do the following:

• call on the telephone


• ask your question


• wait while the bureaucrat looked up your answer in the Medicare Manuals


• gave you their interpretation


• implement your policy change

Fast forward to 2008 when, if you have a question about Medicare, you can open your handy electronic copy of Transmittal 88 using the Adobe Acrobat Reader (available for free) and plug in your question to the search bar.

Curious about Medical Necessity for Physical Therapy?

What exactly do the regs say?

A quick search (<5 seconds) returns 10 instances of 'Medical Necessity' in Transmittal 88. That should get you started.

But my original premise is that many physical therapists think the Medicare Manuals are written by bureaucrats without the patients' best interests at heart.

Why should physical therapists pay attention to policy written by bureaucrats (other than the police powers exercised by Medicare)?

Pay attention to this post by Larry Benz,PT posted at the Yahoo Groups PT Manager listserve

"The medicare superimposed rules have been written by beaurocrats (sic) and our profession has acquiesced or have had "small victories" that have been alluded to that only refine them.


At the end of the day, these additional "standards" cause increased monitoring costs and take away time from patients.
If the over regulated medicare rules become de facto as is being pursued by multiple folks within the PT world, there will not be a viable outpatient PT economic model."

The obvious answer is that bureaucrats don't write Medicare regulations in a vacuum.

Medicare consults with physical therapists like Rick Gawenda, President of the APTA Section on Administration and Steve Levine of the Rehabilitation Consulting and Resource Institute to implement changes to there Manual system.

The three 'bottom line' criteria that define a compliant Medicare plan of care are these:

1) Can the physical therapist demonstrate the medical necessity for physical therapy?

2) Can the physical therapist (or the PTA) demonstrate skilled therapy for each billed procedure?

3) Can the physical therapist show an expectation of a significant improvement in measurable patient function n a reasonable time frame?

If you do good PT the first time then there are no 'increased monitoring costs'.

Good PT begins with Physical Therapy Diagnosis, just like the physicians do it.

Value Centered Physical Therapy

This post comes from a thread in the Yahoo Groups PT Manager listserve between Rick Gawenda, APTA Adminstration Section President and Larry Benz, PT of MyPhysicalTherapySpace.com which discusses the perception that commercial insurance companies like UnitedHealthGroup are trying to emulate Medicare.

This is seen as bad by many physical therapists since Medicare is the most restrictive payer from the notes and charts compliance standpoint.

Medicare also has police powers. That is, if you mess up they may put you in jail.

If there is an organized attempt to model commercial insurance after Medicare then that is news to me.

But, come to think of it - why not?

If we hold Medicare as the standard-setting authority (since professional consensus and practice guidelines don't have any teeth) then could physical therapists follow just one standard?

Can we reduce the goals of the Medicare Manuals (like Transmittal 88) to their intended essence?

The more simple the interpretation of Medicare regulation the easier will be physical therapist compliance and the better will be patient care.

Correct me if I'm wrong (and I'm sure you will) but the Medicare Manuals (and their cousins the Local Coverage Determinations) are aimed at producing three things:

1) that physical therapists demonstrate the medical necessity of physical therapy in their charts and notes.

2) that physical therapists demonstrate that each intervention billed is skilled.

3) that the patient is expected to show significant improvement in measurable function as a result of the physical therapy.

Reimbursement aside, these criteria make for good physical therapy!

If student physical therapists (and old-school professionals) were trained to treat patients with these three criteria in mind then everybody would benefit.

- therapists would benefit from reduced documentation burden (drop the SOAP!)

- therapists managers and administrators would benefit from fewer regulatory constraints by following one standard.

- patients would benefit by increasing focus on measurable function and fewer symptom-oriented and pathology-oriented treatments.

- insurance companies (including Medicare) would benefit from greater transparency in physical therapy charts and notes.

When I graduated in 1992 from the University of Florida I had no training in the disablement model, in physical therapy diagnosis or in describing the medical necessity for physical therapy.

I thought the physician determined medical necessity! (maybe in 1992 they did).

Anyways, it's high time we standardized the 'rules of the road' for physical therapists and physical therapy managers.

If anyone is keeping score then they can count my vote for regulatory standards in physical therapy.

Is the Nintendo Wii Skilled Physical Therapy?

You can go buy the Nintendo Wii Gaming System from Circuit City for $249.99.

I haven't done this but I could buy the Nintendo Wii Gaming System and use it in my physical therapy clinic billing patients for Therapeutic Activities (97530) or Therapeutic Exercise (97110) all day long.

You could also buy the Wii Fit Balance Board from Circuit City for $89.99 and put that in your physical therapy clinic, too.

Apparently, many physical and occupational clinics have done just that.

"Herrin Hospital in southern Illinois, about 100 miles southeast of St. Louis, bought a Wii system for rehab patients late last year.

At Walter Reed Army Medical Center, the (Wii) therapy is well-suited to patients injured during combat in Iraq, said Lt. Col. Stephanie Daugherty, Walter Reed's chief of occupational therapy."

I live in a resort community on the west coast of Florida and many of my retired patients would love to come to me for rehabilitation focused around their tennis or golf lifestyles.

Some physical therapists have declared that Wii is inappropriate in the physical therapy clinic,. Larry Benz is a physical therapist with a large following who has posted on multiple occasions at MyPhysicalTherapySpace.com about his displeasure with the Wii.

My position on the Wii (and technology in physical therapy in general) is this: Does it help the patient?

If technology (including the Wii) is good for the patient then we should consider its use.

I have not ready Larry Benz' every post so maybe he has already brought this next point up.

Is Wii skilled therapy?

Every third-party payer requires physical therapy be skilled physical therapy. Most insurance contracts have a 'boilerplate' section that mentions this.

Only Medicare has police powers so we usually just talk about Medicare requiring evidence of skilled therapy in the daily Treatment Encounter Notes.

Transmittal 88 has a specific definition of skilled therapy, as follows:

"Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently. A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period." (page 25)

This next section is repetitive but bears on the Wii issue...

"Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by
providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services." (page 42)

What is missing from the Wii debate is the diagnosis.

What is the specific impairment, addressed by the Wii, that is addressed that when treated, will significantly improve patient function?

Also from Transmittal 88...

"A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant."(page 27)

To paraphrase Hippocrates, "First, a physical therapy diagnosis".

Regional Interdependence and Finding Normal

Regional interdependence is a concept familiar to physical therapists treating orthopedic conditions.

Regional interdependence is the following:

1. finding hip involvement in patients with primary knee pain


2. finding hip involvement in patients with primary low back pain


3. finding thoracic involvement in patients with primary neck pain


4. finding thoracic involvement in patients with primary shoulder pain
   
   (Wainner RS, Whitman JS, Cleland JA, Flynn, TW. Regional Interdepedence: A Musculoskeletal Examination Model Whose Time Has Come. JOSPT. Nov. 2007;37(11):658-660.)
   

With experience and training a physical therapist will often recognize patterns of movement that suggest regional interdependence. Wainner's article provides peer-reviewed evidence to support the concept.

While regional interdependence may come easily to orthopedic physical therapists, finding normal may not come easily.

For example, how many physical therapists can say to a patient these words...

"I've completely examined you and I can find no evidence of musculoskeletal invovelement. You are completely normal!"

Finding normal is important to regional interdependence because of the large number of potential musculoskeletal contributors to the primary complaint. For example, impairments in strength and range-of-motion at the hip and the ankle may contribute to primary knee pain.

Thomas Goetz writes in Wired Magazine about 'Finding Normal'.

He states the following...

"...we look not for causes of illness but for risks...But for all sorts of conditions , there's often no definition of normal."

Right now, the orthopedic physical therapy community is fascinated with trying to classify every patient into treatable sub-groups.

What happened to measuring patient characteristics and treating the findings?

I may be old-fashioned but I believe that the more you look for the more you find.

What gets measured gets treated.

Regional interdependence is a powerful concept that needs standards to guide physical therapists in making treatment decisions.

One technique that I'll offer up for public consumption and comment is this measurement that I use to assess hip external rotation.

I find that impairments in this motion (using this technique) often demonstrate hypermobile lumbar rotation.

Hip External Rotation measurement

Using data published on my website, I've found that this measurement correlates with functional limitations using the OPTIMAL scale. The correlation coefficient is 0.40.

I will often use this technique to stabilize a weak hip with primary knee osteoarthritis.

Patients with lumbar pain also respond well to strengthening the hip external rotators.

What's especially helpful though, when treating these conditions, I can test the hip external rotator muscles and, if the finding is normal, I can say to the patient the following:

"You are completely normal"

Regional interdependence may require a Physical Therapy Diagnosis

All physical therapists need to jump on this concept and get comfortable with treating 'the whole patient'.

The February Journal of Orthopedic and Sports Physical Therapy has this article...

Regional Interdependence: A Musculoskeletal Examination
Model Whose Time Has Come

This is a quote from the article...

'A best-practice model for managing patients with musculoskeletal complaints has yet to be identified.'

I disagree. The model exists but it has yet to be well-known. I have discussed the model extensively in this blog and further information is available at www.SimpleScore.com.

Further the authors go on to say the following...

"For example, do you routinely examine the hip region for impairments in patients you are treating for complaints of low back pain or knee pain? Likewise, are you examining the lumbar spine for impairments in patients with primary hip and knee complaints?"

As I noted in my last post, routine Physical Therapy Diagnosis will require many physical therapists to change long held, 'old school' practice patterns that allowed physical therapists to treat under a physician referral while abdicating decision-making authority to protocols, models or back to the physician.

Then, when we want that authority back, we find that others (chiropractors) have already taken the authority or that we never earned the authority.

Virginia Chiropractors can't make a Physical Therapy Diagnosis

You can read this discussion about Virginia chiropractors practicing physical therapy that was 'born' on the Physical Therapist Manager Yahoo Groups and can be read here . You will need to sign in to Yahoo Groups to contribute to the discussion.

It's too bad 'physical therapy privileges' can be awarded to
chiropractors who probably can't do a physical therapy evaluation on a
patient prior to performing treatment.

This letter from the acting Virginia Attorney General states that chiropractors can 'practice physical therapy' when performing techniques and modalities.

Here is last paragraph of letter posted on site:

“Based on the above, I am of the opinion that the statutory changes enacted
by the General Assembly in 2000 were not intended to change, and did nothing
to change, the scope of practice of chiropractors, and I am further of the
opinion that chiropractors may lawfully provide physical therapy modalities
as part of a treatment program for patients and, therefore, practice
physical therapy.

With kindest regards, I am
Very truly yours,

Randolph A. Beales

Acting Attorney General”

I wonder if the Virginia state practice act required a 'physical therapy
diagnosis' prior to any profession administering physical therapy
treatments if that would slow the chiropractors down.

The 'physical therapy diagnosis' would require specific measurement of
impairments in ROM, strength and other physical patient
characteristics and also measurement of functional limitations
(perhaps with the OPTIMAL).

The physical therapist would then hypothesize the 'physical therapy
diagnosis' - the link between the impairments and the functional
limitations.

The physical therapist would then treat the patient using any
combination of techniques - exercise, manipulation, education,
whatever it takes.

The physical therapist would then re-measure the patient
characteristics (ROM, strength, OPTIMAL) to see if any improvement
occurred.

If improvement did occur, the physical therapist could attribute the
benefit to the treatment and render a 'discharge physical therapy
diagnosis'.

I've developed a decision-making process called SIMPLE Physical Therapy Diagnosis with 'how-to' videos, data-collection templates and extensive references at www.SimpleScore.com .

If most physical therapists followed this decision-making process I
bet most chiropractors would hesitate mightily before advertising
their services as anything akin to physical therapy.

The problem is that most physical therapists don't follow this
decision-making process prior to administering physical therapy on a
patient and most chiropractors know this.

If chiropractors thought that physical therapy diagnosis was 'over
their heads' then we would be safe from professional infringement.

Physical Therapy Diagnosis is the only sustainable competitive position that physical therapists have in the rehabilitative marketplace.

The only way to protect that position is by practicing Physical Therapy Diagnosis.

Legislative solutions wont work because economic forces drive legislation. Deeper pockets will prevail.

Physical therapists can beat chiropractors not with better laws but by being better physical therapists.