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.