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.
