"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

Monday, September 29, 2008

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.

Sunday, September 28, 2008

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.

Friday, September 26, 2008

Physical therapists: Use the ICF Browser to make your diagnosis


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.


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 - codeBody Functions - codeBody Structures - code
Difficulty Lying - d4150Pain in leg - b28015Lumbar 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.

Tuesday, September 23, 2008

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 .

Sunday, September 21, 2008

Physical Therapy Diagnosis: Label or Process?

The new International Classification of Functioning, Disability and Health (ICF) speaks to the central decision physical therapists make in clinical practice:

What is wrong with the patient?

The ICF model seems to avoid the use of descriptors, or labels, that can be used to describe conditions related to human movement.

Fine with me.

The ICF Browser has descriptors of the following:
  • Body Functions
  • Body Structures
  • Activity and Participation
  • Environmental Factors
...that affect human movement and function.

Using ICF, I could make a diagnosis on a patient with neck pain that would look something like this...
"Patient has difficulty Bending, Sitting and Pushing (all measured by OPTIMAL scale) due to the following:
  1. Stiff upper cervical sidebending (C0-C2).

  2. Weak deep cervical flexors (DCF) muscles (measured by flexor muscle endurance test).

  3. Decreased cervical rotation ROM, bilateral.
...to be treated with the following...
  1. Therapeutic Exercise (97110) for endurance of DCF muscles.
  2. Manual therapy (97140) for ROM, PROM, massage.
  3. Neuromuscular Reeducation (97112) to distinguish cervical sidebending from cervical rotation.
  4. Therapeutic Activities (97530) for Pushing with a stabilized cervical spine."
The descriptors used in ICF all have to do with measured findings.

The descriptors for the above diagnosis are the following:

Body Function:
  • Mobility of several joints (b7101)
  • Endurance of isolated muscles (b7400)
Body Structure
  • Ligaments and Fasciae of the Head and Neck (s7105)
  • Bending (d4105)
  • Sitting (d4103)
  • Pushing (d4451)
Without inventing a nomenclature or supposing the existence of any mechanism or model the physical therapist is able to accurately identify the structure at fault, the proposed treatment and the effect on the patient.

I make this diagnosis about 5-6 times per week.

Most of my patients (60%) are Medicare beneficiaries with typical, routine presentations that require a typical, routine evaluation.

I don't try to 're-invent the wheel' for each new patient I see.

I do take measurements for each descriptor listed above.

I should be able to describe to anybody the patients I treat, the intervention I use and the outcomes I expect.

'Anybody' includes the following...

  • the patient
  • the physician
  • my physical therapist and physical therapist assistant peers
  • third party payers
  • federal policymakers
  • national and international health researchers
  • rehabilitation professionals from related professions
  • the man on the street (?)
If you still want to use physical therapy diagnostic labels you will have to answer Dr. Andrew Guccione's question...

"What concepts are necessary to structure clinical observations into a recognizable pattern that also suggests physical therapy intervention?"

Generally, I recommend the ICF model to any physical therapist who wants to do a good job of treating function.

Specifically, I recommend the ICF model to any private practice physical therapist who wants to generate Bulletproof Physical Therapy Notes and Charts for Medicare compliance purposes.

Tuesday, September 16, 2008

Physical Therapists in Florida included in the RAC Rollout

Physical therapists in Florida are in the first round of states receiving provider education beginning October 1, 2008 according to an article in the September 11 AHA News.

The Medicare RAC Program is designed to augment exiting Medicare audit capacity and, in the words of former CMS Administrator Mark McClellan, M.D., Ph.D...

“There are two parts to making certain that Medicare dollars go to their intended purposes,” said CMS Administrator Mark McClellan, M.D., Ph.D. “First, we need clear and straightforward rules to assure that fair payments are made for services to Medicare beneficiaries and second we need effective mechanisms in place to detect and respond to inappropriate billing. In conjunction with new steps to ensure Medicare’s billing rules are clear, this demonstration will let us test a new approach to ensure that payments made to providers are accurate.”

This RAC expansion map shows the states affected on October 11.

My experience in Medicare Part B outpatient physical therapy is that the RAC audits affected PT's in Florida very little..

We had less than $100 in post-pay audits in the four-year scope of the three-year demonstration project.

Overall, Physician Groups had about $19 million seized as part of the RAC demonstration project.

Most of the money came from inpatient hospitals.

Get the full RAC demonstration report here.

Sunday, September 14, 2008

When is a physical therapy diagnosis not a physical therapy diagnosis?

The most recent issue of The Orthopaedic Section's Physical Therapy Practice contains Developing a Physical Therapy Diagnosis for a Patient with Upper-extremity Paresthesia: A Resident's Case Problem by Trevor Lentz, Marty Huegel and Mark Bishop.

The authors state...
"the most likely source of the symptoms was cervical radiculopathy".
The problem is this 'physical therapy diagnosis' of cervical radiculopathy is that it is a medical diagnosis.

Medical doctors can get a little upset when they hear about physical therapists making medical diagnoses.

We can do better.

Instead, why not a functional diagnosis? Why not a physical therapy diagnosis that conforms to the International Classification of Functioning, Disability and Health (ICF) framework?

Using the ICF framework, measure activity limitations and impairments in body structure and function. Link activity limitations to impairments with the physical therapy diagnosis.

According to the article, the patient's symptoms "were limiting his sleep and work tolerance". These are the self-reported activity limitations.

The measured impairments included the following:
  • asymmetric grip strength
  • sensory loss in the C6 dermatome
  • positive Neck Distraction Test
  • positive Upper Limb Tension Tests (A&B)
  • limited cervical rotation bilateral
Why not a physical therapy diagnosis that simply states that the activity limitations were caused by the measured impairments?

"Limited sleep and work tolerance caused by
  • asymmetric grip strength
  • sensory loss in the C6 dermatome
  • positive Neck Distraction Test
  • positive Upper Limb Tension Tests (A&B)
  • limited cervical rotation bilateral
Why do we need a label?

The APTA House of Delegates policy statement on physical therapist diagnosis states...
"The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client."

Especially, why do we need a medical label that does not inform decision-making for physical therapists?

Ivory Tower Statistics

Here's the part where I'll get myself into trouble.

The authors diagnosed this patient based on a larger positive change in post-test probability for cervical radiculopathy than for carpal tunnel syndrome or thoracic outlet syndrome.

Yet when I read the 'exercise flow sheet' I find no treatments that would apply to a 'diagnosis' of cervical radiculopathy that might not also apply to a 'diagnosis' of Thoracic Outlet Syndrome.

So, what's the point?

Why encourage physical therapists to learn and study powerful statistics (likelihood ratios and nomograms) that don't direct daily clinical decision-making?

Use the list of findings to inform the decision-making process of what to include in the plan of care.

Assuming I measured the same impairments on the same patient couldn't I take the list of findings and design a plan of care that lead to the same exercise flow sheet?

  • asymmetric grip strength
  • sensory loss in the C6 dermatome
  • positive Neck Distraction Test - Manual Cervical Distraction
  • positive Upper Limb Tension Tests (A&B)- Cervical Stretches
  • limited cervical rotation bilateral - AROM
There, I didn't have to use any statistics to make a similar plan of care from the same list of findings.

Instead of making Physical Therapy Diagnosis more complicated, let's make it easier.

Unfortunately, the aforementioned HOD policy statement does not encourage improving the process. Instead, it sticks with outdated labels...

"In performing the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals."

Emphasize the process, not the label.

Disability does not need a medical diagnosis label.

Disability defies labels because people are more complicated, and more interesting, than pathology.

Tuesday, September 9, 2008

The Functional Classification of Neck Pain

Orthopedic physical therapists need to read this clinical practice guideline from the September 2008 issue of JOSPT.

In addition to using the International Classification of Functioning as the basis for clinical physical therapy decision-making the authors describe, in one place, many of the the tests and measures used to assess cervical impairments.

Especially useful is Table 4 which links subjective and evaluation data to interventions used during treatment.

Not only is Table 4 useful for clinical decision-making but could also be used to support 2 of the 3 criteria for Bulletproof Physical Therapy Charts and Notes

  1. Medical Necessity for Physical Therapy
  2. Skilled Physical Therapy (decision-making)

Written measurements of impairments are 'evidence' for a staff physical therapist to argue their case in the event of an unfavorable Medicare audit.

I recommend using high-quality, evidence-based guidelines such as this one to support not only excellent clinical decisions but also to support your Medicare compliance program.

For more information go to BulletproofPT.com.

Monday, September 8, 2008

Informed Physical Therapists Diagnose using the ICF

Informed physical therapists can make a break with 'old school' models and advance the discussion of physical therapy diagnosis by taking a look at these new APTA resources for the new International Classification of Functioning.

'Old School' models, many of which I have used, include most of the mechanistic models we learned in PT school and at 'Hilton University' (some of you may have gone to 'Marriott U' or 'Holiday Inn U').

To name a few...

The Facet Joint
The Disc (...is a jelly doughnut)
Sacroiliac joint
McConnell taping

Now, with ICF, you can abandon models and just treat the patient.

This new paradigm (new to me since 2001) allows the physical therapist to measure characteristics of the patient that may impact function and apply treatments without regard to the mechanism.

Ah, freedom.

Freedom from justifying my treatments to other PTs, PTA's, patients or payers. If I get my patient better - who cares how I did it or what technique I used?

The power in the ICF model is that I can find freedom while a different PT or PTA can find meaning in a different way.

The ICF is a framework - not a blueprint.

I practice orthopedic PT but the ICF is equally appropriate for neuro PTs.

Use my templates and watch my videos to see how I use the ICF to inform PT orthopedic decision-making.

Free Tutorial

Get free stuff at BulletproofPT.com

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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