A Blow to Autonomous Practice

How much therapy is enough?

Who decides? You?

Maybe not.

The recently published Transmittal 1678 (February 13, 2008) details resources you should use that...

"suggest the amount of certain (physical therapy) services that may be typical, either

• per service
• per episode
• per condition
• per discipline...

The resources are the following...

1. Computer Services Corporation (CSC) Therapy Cap Report, 3/21/2008
2. Computer Services Corporation (CSC) Therapy Edit Tables, 4/14/2008

To summarize:

One in eight physical therapy patients received a -KX modifier in 2006 ($1,740 capped amount).

Florida, New York and New Jersey were the three states with the highest percentage of therapy users over the cap.

These are the three most common physical therapy diagnoses billed to Medicare in 2006.

• 781.2 Abnormality of gait
  
• 724.2 Lumbago
  
• 719.7 Difficulty in walking
  

However, the diagnoses most likely to exceed the cap were different:

• 438.22 - Hemiplegia affecting nondominant side - 31.3%
  
• 438.21 - Hemiplegia affecting dominant side - 30.9%
  
• 438.0 - Cognitive deficits - 30.6%

"In other words, some beneficiaries with diagnoses, although less commonly observed, are more likely to surpass the cap threshold."

Only 2% of physical therapy users who exceeded their capped amounts accessed the hospital to continue their therapy.

Transmittal 1678 suggests that if your billing profile deviates much from these parameters then you may have some explaining to do.

Who wins?

CSC touts the therapy cap exception process as a win for patients (improved access) and for Medicare (lower costs).

Physical therapists, however, are micro-managed, clinical decision-making is aborted and financial risk is shifted to the provider.

Is this sustainable?

No.

Not without the use of financially-motivated third parties (RACS) that treat health care providers as a revenue source.