Physical therapists and doctors: Get ready to hand over more documentation

Much in the news lately is the Office of the Inspector General Investigation of the Comprehensive Error Rate Testing Program.

As I blogged on Sunday, August 24, 2008 you-know-what will run downhill on this one.

Here is the OIG report for your reading.

In summary the report states the following:

"We recommend that CMS:

• require the CERT contractor to review all available supplier documentation;
• establish a written policy to address the appropriate use of clinical inference;
• require the CERT contractor to review all medical records (including, but not limited to, physicians’ records) necessary to determine compliance with applicable requirements on medical necessity;
• document oral guidance that conflicts with written policies, such as guidance on the need for proof-of-delivery documentation in making medical review determinations;
• instruct its Medicare contractors to provide additional training to physicians that focuses on improving their medical record documentation to support ordered DME items; and
• require the CERT contractor to contact the beneficiaries named on high-risk claims, such as claims for power mobility devices, to help determine whether the beneficiaries received these items and the items were medically necessary."

I've highlighted in red the requirement that I believe will lead to tougher audit standards on physical therapists and physicians - already overburdened with declining reimbursements and rising costs.

Physical therapists should not take 'ownership' of physical therapy diagnosis

Physical Therapy Diagnosis is a blog I have posted to since about August 2007. Physical therapy diagnosis is also a topic I have been interested in since about 2005.

I first discovered PT diagnosis in reading the Guide to Physical Therapist Practice (2nd ed.).

The Guide had a reference to the Disablement Model by Nagi. Since then, Nagi's model has been updated by the International Classification of Functioning, Disability and Health (ICF) model which, among other things, replaces Nagi’s ‘functional limitations’ with ‘activity limitations’

The model describes how physical therapists can intervene by identifying the connection between measured activity limitations and measured limitations in body structure and function (Nagi's 'impairments').

Physical therapists identify the link and that process is the physical therapy diagnosis.

I can only say that I wish I had learned the disablement model in my undergraduate education. To say that my physical therapy practice patterns have evolved since adopting theis framework would be an understatement.

Not evolution, but revolution.

Imagine my surprise to learn that 'Physical Therapy Diagnosis' is a term not recommended for physical therapists by none other than the foremost author on functional assessment in physical therapy...

...Alan Jette, PT.

I found his 1989 article Diagnosis and Classification by Physical Therapists: A Special Communication in which he briefly discusses his thoughts on the matter...

"There are pitfalls along the way into which physical therapists might easily fall. One that particularly concerns me is the use of the phrase 'physical therapy diagnosis.' I concur with Sahrmann, who recommends that the term "diagnosis" be used by the physical therapist in referring to the identified condition that is the focus of the physical therapist's treatment. It should not be used to reflect ownership of the condition, which would be the inevitable consequence of using the phrase 'physical therapy diagnosis.'"

(Jette, 968-969)
I don't know how much has changed in the last 19 years...

Are we in danger of alienating ourselves from physicians if we persist in using the term 'physical therapy diagnosis'?

Has there been a surge in professional diagnoses?

• nursing diagnosis
• chiropractors diagnosis
• personal trainers diagnosis

It may be too late for me.

I've already taken a position on this issue. It's changed my life and my practice.

What about you?

Medicare Auditors Get Spanked

Health care providers can expect this one to flow downhill like you-know-what.

All across the blogosphere, reports of the draft report from the HHS Office of the Inspector General are streaming in...

Miami Herald Aug. 21

ProPublica Aug. 22

Tampa Tribune Aug. 21

Judicial Watch Aug. 22

Looking for the Outliers Aug. 23

Who Will Audit the Auditors? Aug. 22

Medicare claims $700 million in fraudulent savings to the federal health care program for elderly and disabled persons.

The New York Times (Aug. 20) claims the amount should be over 4 times that amount - almost $3.2 billion - that may have been swindled by unscrupulous medical device providers like wheelchairs and motorized carts.

Medicare failed to follow its own internal accounting controls in estimating the amount of fraud.

Congress and Senator Charles Grassley
are mad.

"I want to know what happened, who's responsible, who will be held accountable and what the [Human Services] secretary will do about it," said the senator, who was briefed on the draft report. "If people cooked the books, manipulated the methodology or told the contractor to ignore the rules, those individuals need to take the heat."

If Congress spanks Medicare you can expect Medicare to spank providers with tougher audits.

All providers will suffer for the actions of a few - and for the actions of a watchdog agency that tried to cut a few corners.

Medicare Messed Up

Physical therapists should pay attention to this new Office of the Inspector General (OIG) Report that claims the Centers for Medicare and Medicaid Services (CMS) under reported fraud in durable medical equipment (DME).

"The report found that in fiscal year 2006, CMS failed to detect that more than one-third of spending on DME was fraudulent."

More than one blog picked up the story from the New York Times today based on a draft report obtained by the Times.

The full report should be out this week or next.

Medicare fraud was under reported by CMs when they claimed the false claims error rate for DME was 7.5% for 2006 when actually, according to the OIG, the true error rate was 31.5%.

“This is outrageous,” said Senator Charles E. Grassley of Iowa, the top-ranking Republican on the Senate Finance Committee, who has repeatedly credited the Centers for Medicare and Medicaid Services with reducing improper expenditures. “If heads don’t roll, you can’t change the culture of this organization,” he added." (source - NYT)

Honest, hardworking physical therapists may now have to put up with increasingly burdensome audit and regulatory measures.

Physical Therapists Watch out for auditors in U-haul trailers at your office!

Did you work all day treating patients?

Tired?

Ready to relax?

But wait, don't you have to update your Medicare compliance plan?

Remember the one sitting on the shelf? Or, the one you've been meaning to work on?

Well, take heart...

I've assembled some resources that will help get you started or further along to completion.

The first is this recent article...

Altering Medical Records: What Not To Do When Being Audited By Medicare : Physician Law

The article is published on the blog of attorney Todd Rodriguez, who specializes in Medicare fraud.

This next resource is a recent post from the Physical Therapy Manager (PT Manager) list-serve at Yahoo Groups. You may be required to join the group.

The list is moderated but most physical therapists, administrators and some medical doctors and chiropractors have managed to get on.

Look for Victoria Cavitt's post from July 30, 2008 (she is replying to Jim Hall, CPA) and she talks about 'U-haul trailers with copiers' - here is a sample...

"They show up at your practice with U-haul trucks that house their own
copiers and OIG agents serve you a subpoena to access ALL your medical
records.

Medicaid and OIG employees randomly pull patient charts off your shelf, copy
these charts in their U-haul trailers, and look for patterns of inaccurate
billing and insufficient documentation. They don't give you advance notice of their arrival..."

That post got my attention - I kept thinking about those U-haul trailer all day at work! And I have a great Medicare compliance plan that meets all of Victoria's criteria.

I got my plan from the source documents - I'll tell you where to get those in just a minute - but first you should take a look at the basis for any Medicare compliance plan.

The DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Inspector General Compliance Program for Individual and Small Group Physician Practices is the authorizing document for any small practice tying to 'do-it-yourself' when it comes to compliance.

"We believe that the development and issuance of this voluntary compliance program guidance for individual and small group physician practices will serve as a positive step towards assisting providers in preventing the submission of erroneous claims or engaging in unlawful conduct involving the Federal health care programs."

Finally, I have this OIG document, the Medicare Manuals, an many more physical therapy specific resources all available for download at BulletproofPT.com.

You can get a free compliance tutorial that gives you 13 tips and strategies to 'bulletproof' your physical therapy practice.

Don't let the U-hauls get you.

Get Bulletproof PT today.

The Pragmatic Physical Therapist Avoids Models

I recommend the August 2008 Physical Therapy Journal for the Case Report titled

Process for Applying the International Classification of Functioning, Disability and Health Model to a Patient With Patellar Dislocation by Kevin Helgeson and A Russell Smith Jr

(subscription required)

I blogged about this article just two days ago

The patient was an active 23-year old female graduate student who wanted to return to hiking and running.

"She sustained the following... second-degree tear of the medial collateral ligament (MCL) of the right knee, with a lateral dislocation of the patella. She was referred for magnetic resonance imaging (MRI) of her right knee; the MRI was performed the following week. The MRI findings reported by the radiologist were “sprain of the medial collateral ligament with overlying edema and bone bruises of the posterior medial tibial plateau and of the lateral femoral condyle with a small knee joint effusion.”

What I found helpful was Helgeson and Smith's pragmatic approach to decision-making.

"The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was reevaluated through an assessment of the level of improvement of the patient’s primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

By pragmatic I mean the ability to change the plan of care based on the patient's response, measured at the level of the functional ability - in this case walking, hiking and squatting.

This pragmatic approach avoids the use of models - simplifications of human structure and function that are used as aids to decision-making.

The pragmatic approach relies on test data, functional ability, to make decisions.

I would have used the OPTIMAL test to measure functional ability.

The problem, as I see it, is that the use of test data to make decisions 'pigeonholes' physical therapists - that is, it forces them to make decisions that might be contrary to their favorite model or treatment technique.

Full disclosure: My favorite treatment technique for lower back pain is spinal stabilization.

When stabilization doesn't work, as indicated by my OPTIMAL score, I am forced to resort to other means, such as ultrasound or massage to treat the patient.

I don't like it - but I do it.

I wonder if other physical therapists are similarly vexed by using data?

Or, do you just stick with the model?

Physical Therapy and the Angry Bear

The Angry Bear is an economics and health care blog that explains in common, rational terms what is happening in health care.

Most of the posts I've read are well-written.

Read this Angry Bear post and then read this comment that begins like so...

"The problem of paying for health care comes to down to one simple truism: no one wants to die."

When it comes to our our health or the health of our loved ones the ability to act and behave rationally is difficult.

Physical Therapist uses the ICF model for Decision-Making

This is the first physical therapy article (that I have seen) since the APTA adopted the International Classification of Functioning (ICF) framework in June 2008 that uses the framework for decision-making.

I've used the framework when it was called the International Classification of Disability, Impairments and Handicaps (ICDIH) since late 2007, when I started writing this blog on Physical Therapy Diagnosis.

I've found the process liberating.

I feel more able to help my patients and at the same time I feel less personal responsibility if those patients fail to improve with physical therapy.

I just take the measurements (impairments and abilities).

I find the link - the Physical Therapy Diagnosis.

The treatments are more or less routine.

Back to the article...

This case report by Kevin Helgeson, PT, DHSc describes the treatment of a 23-year old girl with a recurrent patellar dislocation. The measurements and treatments described in the article are pretty routine: exercise, patellar gides, proprioceptive training, etc.

What I found interesting, in the 'Discussion' was the authors' comments on their decision-making process.

"An important aspect of this evaluation process in the ability to reevaluate the interrelationships within the ICF framework and decisions made throughout the course of treatment. The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was re-evaluated through an assessment of the level of improvement of the patient's primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

I can use this in my practice.

We use the OPTIMAL scale. We use the OPTIMAL to write Bulletproof PT Notes for Medicare compliance.

For example, I follow-up with a patient using the OPTIMAL.

They are not making progress with walking long distances. Their goal is 2/5 OPTIMAL. I record their current score, 4/5 (lower scores are better).

Based on their failure to improve, I decide to change their plan of care and try again.

I have just demonstrated skilled physical therapy using my decision-making. The OPTIMAL was my tool and the ICF was my framework.

You can see more examples of skilled physical therapy using the OPTIMAL (and other tests) within the ICF framework. It's all Medicare compliant. It's called Bulletproof Physical Therapy Charts and Notes.

What Alternatives for Physical Therapy?

The Outpatient Therapy Payment Alternative Project Synopsis is at the point of data collection...

"In order to collect the needed data, the project involves (1) the development of a data collection strategy, including the recruitment of therapy providers to participate in data collection..."

The Project needs to collect data on how to measure the patients you see in physical therapy every day.

Medicare would like to know three things

1. How disabled are they?
2. How much will they improve with physical therapy?
3. How disabled will they be at discharge?

"The Medicare Payment Advisory Committee (MedPAC), the Government Accountability Office (GAO), and outpatient therapy stakeholder organizations have suggested that the claims and administrative data currently available to CMS are not sufficient as the basis for developing better alternatives to the therapy caps."

Right now, the data collection instrument looks like it will be the Activity Measure for Post Acute Care (AM-PAC).

"the AM-PAC was designed to be used across patient diagnoses,
conditions and settings where post acute care is being provided"

.
I currently use the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) and I like it.
This project may dovetail with other projects ongoing at Medicare.

The Physician Quality Reporting Initiative (PQRI), affectionately known as Pay for Performance (P4P)may become a part of the Alternative Payment Model.

The American Physical Therapy Association (APTA) is working on a payment model (an alternative to the 'Alternative') that will pay providers more when the patient gets better in less than the expected number of visits.

"Value Purchasing in Outpatient Physical Therapy" by Alphonse Amato, PT, MBA in 2006 laid out a similar-sounding plan.

Go read it.

It sounds like a blueprint for the future.

Depends on who gets their way.

Developing Outpatient Therapy Alternatives

I just participated in an open-door session with the company that contracts with Medicare to develop a new way to pay physical therapists.

The firm, RTI International, has developed a web page called Developing Outpatient Therapy Alternatives that will have resources for clinicians to study an anticipation of the new measurement instruments.

On August 13th, the podcast of today's free, two-hour open door session will become available and I will post of provide a link here.

The new payment system is designed to prevent a re-occurrence of the Congressional/Executive S.N.A.F.U. on July 1 that I blogged about here, here and here.

Bottom line, the new payment system is seeking a way to 'risk adjust' patients so that Medicare can pay $50 for a simple ankle sprain and $2000 fro a complicated rotator cuff rehab. These numbers are make-believe but they make the point.

Consider for example two patients - each has the diagnosis 724.4 (Lower Back Pain). All Medicare has now is data from the claim form: that is the diagnosis 724.4 and the billed charge.

By the way, 724.4 is not a physical therapy diagnosis, it's just a CPT code that conveys little actual information.

Medicare would like information that helps them do the following:

1. Anticipate cost
2. Know how bad the patient is
3. Know how long the patient will be seen
4. Know how much better the patient will get

The new measurement instrument would most likely be a paper or web-based questionnaire that the patient and the clinician fill out together and update regularly, possibly as part of the Medicare Progress Note (every 30 calendar days or 10 treatment session - whichever is less).

Frustrating Fraud in Medicare

Tannus Quatre, PT, MBA has done a nice job in his blog of articulating the feelings I think many PT's share in trying to stay compliant in a complex health care system.

South Florida: The nation’s capital for Medicare fraud tells the story of a Medicare provider with a prior drug conviction who ran a scam stealing millions of dollars from Medicare.

Meanwhile, hard-working health care providers struggle to stay compliant and to keep the dollars they have earned.

Thanks to Tannus - go check out his blog.

New Physical Therapy Medicare Progress Note

We have just updated our proprietary physical therapy Progress Note for Medicare.

The latest revision is consistent with the American Physical Therapy Association's recent endorsement of the World Health Organization's (WHO) 2001 International Classification of Function, Disability and Health (ICF).

The new Progress Note is posted at Bulletproof PT Charts.

The Progress Note is a template and is free to use.

You still have the responsibility to determine medical necessity for physical therapy, demonstrate skilled therapy and show expected improvement.

This note is just a tool to help you get there.

You have to scroll down the page a little to 'Medicare Progress Note and Re-Certification'.

You may need to modify the note to fit the needs of your PT facility.

The note is based on the ICF framework (Participation, Abilities and Body Structure/Function).

The note uses the OPTIMAL scale, baseline and follow-up, for outcomes measurement.

To learn more about a fully compliant physical therapy note and chart visit Bulletproof-PT-Charts.com.

Free free to use the note - if you have feedback either way, good or bad, please tell us to your experience.

Just comment to this blog.

Thanks.