"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

Saturday, October 11, 2008

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.


  1. You know that the 4 visit max had everything to do with the Ortho owning his own PT clinic. It amazes me that Orthos are never satisfied with making $750K on their own but they have to own a PT clinic to get even more money coming their way.

  2. Dear Anonymous,

    Could be.

    It could also just be ignorance on his part.

    I have heard other PT clinics say the same thing - they limit patient access to care because they were unwilling or afraid to append the -KX modifier to their billed charges.

    The cap is an obstacle that does contain costs.

    The OTAPS 2 Utilization study did indicate that the greatest impact of the caps was on the variance per episode paid and the variance per episode days.

    In other words the cap got rid of the outliers in outpatient PT.

    Thanks for your response.


  3. Let's face it, as long as there is $$ to be made there will be corruption. The best thing for patients to do at this point is to research and arm themselves with information and make a rational decision on how they are progressing in their treatment.

  4. The pushback I've had from industry leaders in the PT space is that POPTs increase utilization by 30% and reimbursement by 40%.

    Their logic seems to be "the rising tide floats all boats" sort of rationale.

    However, this sort of status quo thinking is not what propels health system change for the better.

    Thanks for your comment.



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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

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