What will replace the OPTIMAL?

I get a lot of feedback on this blog from physical therapists who don't much like the OPTIMAL scale.

Some say they use it because it's 'recommended' by Medicare, not because it's a good outcomes scale.

Some of the problems with the OPTIMAL scale that physical therapists relate to me are:

• Too general
• No descriptors of the activities (eg: long distance walking)
• Inappropriate for elderly persons (eg: running, hopping and jumping)
• Too long (21 activities)
  

This is just a short list...

Additionally, the American Physical Therapy Association has gone on record saying the OPTIMAL has not fulfilled its intended mission:

...to be the single, disease-specific treatment planning and goal-setting tool for outpatient physical therapy Medicare compliance and outcomes measurement. (my emphasis)

Nevertheless, the APTA maintains the OPTIMAL page on its website and offers free licensing for clinical physical therapy use until a superior alternative is found.

What are the alternatives?

Now, be aware that these are commercial (NOT free) alternatives that offer some enhancement over a pen-and-paper tool like the OPTIMAL.

CARE tool (May 2009)

AM-PAC (required by 2012?)

FOTO

There may be others, like the following:

• Neck and Back Index
  
• Oswestry scale
  
• Lower Extremity Functional Scale
  
• Patient-Specific Functional Scale

...and others, that are acceptable overall outcomes measures but are not recommended by Medicare.

Acceptable outcome measures have usually gone through the peer review process and are published in a professional journal and are accepted by a consensus.

What is the trade-off?

The trade-off for comprehensiveness is time.

A tool that is disease-specific requires multiple templates for different body parts or regions (eg: Neck and Back Index).

A tool that is more comprehensive is longer and harder for the patient to complete.

A longer tool may be more difficult for the clinician to score.

A commercial tool, today, offer few benefits over the free tool.

The OPTIMAL is brief and simple to score.

My own recommendation, today, is for the clinician to use the OPTIMAL.

What is the time frame?

In May 2009, Research Triangle International (RTI) will begin a pilot project to develop a new measurement tool to find

"...better information tied to patient need and the effectiveness of outpatient therapy services."

Between 2012 and 2014 the pilot project will wrap up and, presumably, physical therapists will have a needs-based, risk-adjusted tool to assess their patients, in acute, hospital-based and outpatient clinics.

What if you do nothing?

Even if you don't adopt a commercial tool today that, realistically, will segue into the recommended tool by 2012 you should be using the free tool.

Doing nothing is not an option.

A Medicare auditor looking at your files may consider the absence of any outcomes tool as 'blatant disregard' of published recommendations.

Get your systems in place now.

The easiest, simplest system today is the OPTIMAL baseline and follow-up scale.

Use outcomes measures to measure your effectiveness because it's good physical therapy.

Use outcomes measures to improve your Medicare compliance because you can't afford not to do so.

Can Physical Therapists Treat Pain?

When I attended the University of Florida one of my physical therapy professors gave me this advice:

“Treating pain is a moral decision that may not be your primary therapeutic focus – treat function, not pain.”

At the time I wondered what my professor meant – treating physical dysfunction as the cause of pain in a way that alleviated the pain itself. This was a technique that eluded me for several more years.

I graduated from my university in 1992 without the benefit of learning the International Classification of Impairment, Disability and Handicap model (ICIDH) from the World Health Organization (WHO) for decision-making.

The ICIDH was first published in 1980 but it was intended for coding and manipulating data (eg: treatment codes), not for treatment decisions.

In 2001, WHO updated the ICIDH framework and re-named it the International Classification of Functioning, Disability and Health (ICF).

In June 2008, the American Physical Therapy Association (APTA) endorsed the ICF model.

“The model acknowledges that every human being can experience some level of "disability" and views functioning and disability as an interaction between health, the environment, personal and social factors.”

The new ICF framework, in my opinion and the opinion of others, greatly improves physical therapists’ ability to make treatment-planning decisions in the clinical setting.

“In clinical settings ICF is used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement.”

Making correct decisions as to the choice of treatment intervention at the initial evaluation will speed the acquisition of good patient handling skills and, ultimately, the collection of good data.

The evidence for function

Physical therapists consistently demonstrate an ability to improve function, reduce costs and healthcare utilization and generate satisfied patients. Physical therapists achieve these outcomes by focusing treatments on measured functional deficits.

Note: The references are available in the Bibliography at www.BulletproofPT.com.

Jewell DV and Riddle DL examined 1,804 patients diagnosed with sciatica and their response to physical therapy. Twenty-six (26%) of the patients (n=473) had a meaningful response on a follow-up questionnaire.

Patients who received joint mobility interventions and exercise were more likely to improve on the follow-up questionnaire than patients who received ‘spasm reduction’ interventions. Spasm reduction interventions included ultrasound, electric stimulation, heat and ice.

Another study, this one by Deyle GA et al reported on two groups of patients with knee osteoarthritis – one group received ‘manual physical therapy and exercise’ while the other group received de-tuned ultrasound. Eight weeks later, the treatment group receiving manual physical therapy and exercise improved 55.8% on the outcome questionnaire and 13.1% in distance in a six-minute walk. The control group that received de-tuned ultrasound showed no improvement.

A follow-up study by Deyle GA et al showed the effectiveness of skilled physical therapy over a home exercise program in 134 patients. By eight weeks the clinic treatment group had improved 52% while the home exercise group improved only 26%.

Subjects in the clinic exercise group were less likely to be taking their medications and were more satisfied with the results of their rehabilitation.

Finally, Fritz et al showed in a sample of 471 patients with acute low back pain that ‘adherence to the recommendation for active care’ decreased physical therapy visits, lowered physical therapy charges and led to greater improvements in pain and disability. A one-year follow-up showed that patients receiving ‘adherent care’ were associated with lower prescription medication usage, fewer MRI scans and fewer epidural steroid injections.

The evidence for pain

One study, cited by Medicare in its Physicans’ Quality Reporting Initiative (PQRI) Summary of Quality Measure Reporting Provision for 2009, instructed physical therapists and other eligible providers to assess pain prior to the initiation of therapy.

The Summary states the following:

“Reducing the intensity of pain by just 25% has been shown to achieve a 50% improvement in functional status”. 

Treat pain and measure function

One wise therapist helped me understand that we can do both - treat pain and measure function.

Physical therapists too often feel compelled to treat pain with modalities and throw in exercise and functional training if there is any time or dollars left over.

Pain is an impairment – an impairment that can be measured.

Pain is, however, just one impairment of many impairments that can be measured using new tools available to physical therapists.

Available tools (both free and paid) include the following:

• OPTIMAL difficulty and confidence scale (free)

• AM-PAC mobility and activity scale (paid)

• ICF disability framework (free)

• APTA Interactive Guide to Physical Therapist Practice, With Catalog of Tests and Measures (paid)

• FOTO (paid)

Futhermore, according to the ICF, pain will affect patient activities and participation differently in different people.

For a Bulletproof Chart, both pain and function can and should be measured.

Treating pain by improving function and movement is one of the essential skill sets of the physical therapist.

The physical therapist, using skilled decisions and judgment, links the various measured elements using the physical therapists’ diagnosis.

A physical therapist sticks to his knitting

I hang with physical therapists.

I stick to my knitting.

Here at Physical Therapy Diagnosis I try to provide the point of view of a private practice physical therapist trying to understand and cope with the United States health care system in general and Medicare in particular.

Lately, I've blogged a lot about the Medicare Recovery Audit Contractors (RACS).

Sometimes, though, you may want the full story - a comprehensive approach.

I've linked to this timely update on 'news' involving the RACs.

This blog offers a timely update on RACs, primarily on their impact on long-term acute care hospitals.

Keep looking at all the posts on this blog for some in-depth analysis of RACs and their specific impact on physical therapists.

How do physical therapists make decisions?

Physical therapists (PT) usually treat 11-15 patients per day in outpatient orthopedic clinics.

Most PTs in the United States still use a pen-and-paper approach to note writing.

We scribble all day long in between running to patient treatments.

Medicare only has these written notes to examine to determine if the physical therapy treatments are worth paying for.

What do most PT charts look like and what decisions do they reflect?

Get some perspective

Step back for a minute.

Stop writing your note.

Stop being a PT or PTA.

Look at your chart.

What does it look like?

Is it organized?

Neat?

Sequentially organized?

Are the most important documents on top?

Does it look like you chart is designed for fast, efficient treatment?

Or, does it look like your chart is designed for fast, efficient decisions?

What do skilled physical therapy decisions look like?

Your skilled physical therapist decisions are what Medicare is paying for.

Treatment is secondary to your decisions.

Make the chart work for you.

Set up your chart so that evidence of decision-making is foremost.

Put your goals at the front of the chart.

Make decisions about goals in the daily note. If you still use a SOAP note the Assessment portion should reflect progress towards goals.

Make your initial measurements accessible. Put your dictated Plan of Care where you can get to it easily (hint: not at the back of the chart).

Two types of measurement need to be accessible:

1. Impairment in body structure and function (ICF)

2. Activity and participation limitations (OPTIMAL)

Put these near the front of the chart.

Some therapists feel that the back of a double-sided, flip-type paper chart is just as accessible by grabbing the whole stack of paper and flipping it up.

Perhaps it is.

I think that putting your goals and measurements at the back of the chart however sends the subtle message that you see writing about goals as less important.

Goals are less apparent and less evident at the back.

The presentation of your chart should reflect your intent.

What is your intent?

Decisions or treatment?

Decisions are more defensible.

*****

To get an incredibly detailed, voluminous, technical and shelf-worthy resource on physical therapy do-it-yourself Medicare compliance go to the

Compliance Program for Individual and Small Group Physician Practices

by the Office of the Inspector General.

To get a compliance program written by a physical therapist for physical therapists go to

BulletproofPT.com

written by Tim Richardson, PT.

Own Your Own PT Clinic

Own your own PT clinic.

Owning your clinic is the dream of many smart, young physical therapists.

Treat how you feel your patients should be treated.

Do good work.

Get paid.

That's how I got started.

But I started with partners and I bought them out.

Out with the old and in with the new.

That's what I thought, at the time.

It was all mine.

*****

Then I looked around.

And there it was...

Something old, still there.

Sitting on the shelf, dusty.

An old three-ring binder.

Pages yellow with age.

When I opened it, I sneezed.

Dust flew off of the page, around my eyes.

It was the old clinic Medicare compliance manual.

Never opened.

Never updated.

Inside were ten, yellow typewritten pages.

Typewritten... On a typewriter.

The Manual

The pages contained, believe it or not, instructions on how to assemble hot packs and instructions to aides on how to treat patients.

There was actually a copy of a referral pad with a physicians' signature line that stated the following:

"These treatments are Medically Necessary for the patient to receive physical therapy services."

There was a diagram of the floor plan with the fire escapes marked in faded red marker.

The manual had one page that told what to do in the event of a hurricane.

It had another page that listed vacation days.

Wow.

The Date

I found a date.

1988.

That's when I started to panic, a little.

My Action Plan

I decided to get busy building a plan.

I took a seminar by an expert Medicare consultant.

According to the expert, my notes were so far out of compliance there should have been a red, neon label that said "Audit Me!" attached to every charge I sent to Medicare.

That's when I started to panic, a lot.

I decided to learn everything I could about outpatient physical therapy Medicare compliance.

I took more seminars, bought books, read newsletters, called my practice association and, in general, specialized in outpatient physical therapy Medicare compliance.

I excitedly went to my staff, 7 PTs and PTAs.

I told them everything I had learned.

You know what happened?

Big yawn.

Some PTs and PTAs fell asleep during my presentation.

Some were more polite about their disinterest.

Bottom line, the notes and charts didn't get much better.

Why?

It didn't matter.

I hadn't shown my staff why and how Medicare compliance made better physical therapy.

I hadn't shown my staff how they could help their patients more with better notes.

My PTs and PTAs just wanted to treat patients.

They couldn't see why and how notes could help them do that.

I had to do better.

I went back to the drawing board - I made Bulletproof Physical Therapy Notes and Charts.

Bulletproof is uses three, public-domain tools to show physical therapists' decisions - the core of your skill set.

Bulletproof uses templates to show progress and need for PT.

Bulletproof also describes dozens more tips, techniques and strategies for physical therapist mangers and educators to train PTs and PTAs to get Bulletproof Notes and Charts.

There is no three-ring binder to keep from getting dusty.

So far, the results are very encouraging.

My staff and my patients are happier than ever.

We are confident now when we append the -kx modifier, start a second month of therapy or just write a daily note.

Now, I'm not scared anymore.

Finally, I'm living the dream.

How much do RACs cost private practice physicians and physical therapists?

I've been living under the gun for three and a half years.

The RAC gun.

The Medicare Recovery Audit Contractor (RAC) program is a new permanent federal program expected to 'go live' in February 2009.

The initial roll-out is mainly in the northeast and in the RAC demonstration states.

I live in Florida, a demonstration state since 2005.

Recent conversations I've had with my peers and professional organizations indicate that there is a lot of additional anxiety regarding the RACs.

While I never want to downplay the severity or the possibility of a Medicare audit, MAC or RAC, I want to present some information that can help private practice physical therapists assess the risk of and the damage from the RACs.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

Data for this table is available in this report.

Note that physical therapists are lumped in with physicians in the RAC report from which this data is drawn.

$992.7 million dollars in overpayments were recovered from providers, mainly (85%) inpatient hospitals.

Of the $992.7 million only $19 million came from physician practices (which include physical therapists).

40% ($391.3 million) of the overpayments were for medically unnecessary services.

Services are medically unnecessary when the clinician failed to justify why the services were performed.

For physical therapists this usually means measurements of ROM or strength deficits.

Also, measurements of activity limitations.

Finally, link deficits to activity limitations in the physical therapists' diagnosis.

Bulletproof Compliance

Your current Medicare compliance plan should be sufficient to respond to a RAC audit.

If you have a current Medicare compliance plan.

Mine used to be a dusty manila file folder sitting up on a shelf.

Not anymore.

I got busy and got some basic education - available in this blog and at Bulletproof PT.

Get your own compliance program.

Get Bulletproof.

I live under the gun...

But, I sleep well.

Medicare RAC nightmare

I woke last night, sweating and afraid.

I felt my heartbeat pounding in my chest.

I had a nightmare.

I think I cried out because my wife woke, mumbled something and reached out to pat my leg.

In my nightmare, Medicare Recovery Audit Contractors (RAC) were in my PT clinic threatening hefty fines and jail time.

Paper lay in piles all over my office. Charts were open and strewn about on desks.

Copy machines hummed and glowing lights illuminated stern-faced auditors with green eyeshades.

"You're in a lot of trouble Mr. Richardson, did you know that?"

Of course, it was just a nightmare.

I wasn't actually being audited by Medicare RACs.

Some private practice physical therapists may share my anxiety.

For us, the threat of a RAC audit looms large as the expected February 2009 nationwide RAC roll-out approaches.

So what, in the bright light of day, are the known risks of a physical therapist RAC audit?

Here are some of the resources I have compiled to help physical therapists understand RACs.

Hint: It's not all bad.

Outliers

Medical Necessity

Who gets caught?

Advance Beneficiary Notice

Patient Case

RAC expansion schedule

RAC Fact Sheet

OIG Work Plan

Bulletproof Physical Therapy Notes and Charts