"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

Friday, May 15, 2009

Chiropractors need help in writing treatment notes

A new report from the Office of the Inspector General (OIG) on chiropractic services furnished to Medicare patients shows that chiropractors have as much trouble, or more, than physicians or physical therapists in writing notes on their patient care that show: 
  • medical necessity (need)
  • progress 
  • skill (decisions) 
"Medicare inappropriately paid $178 million for chiropractic claims in 2006 (from a total of $466 million in Medicare chiropractic claims) ...
  • 88% of the reviewed claims had inappropriate payments for 'maintenance therapy'
  • 26% for undocumented care
  • 6% for miscoded care
  • 20% of the claims had multiple errors
  • 83 % of chiropractic claims failed to meet one or more of the documentation requirements."
The Comprehensive Error Rate Testing program Paid Claims Error Rate for chiropractors, PM&R physicians and physical therapists in private practice (PTPP) shows the following error rates for the last three years:

CERT Program Provider Error Rates200620072008
PM&R Physicians9.1%7.6%8.9%
Physical Therapists in Private Practice11.3%6.1%7.0%

The provider type with the lowest Paid Claims Error Rate is in bold.

The Executive Director of the Wisconsin Chiropractic Association, Russ Leonard, has called the OIG Report 'discriminatory' because the Medicare definition of 'maintenance therapy' seems to prevent chiropractors from performing chiropractic adjustments "...to maintain or prevent deterioration of a chronic condition."

Since physical therapists are held to the same standard for maintenance therapy the chiropractors claim of discrimination seems unfounded.

The OIG has been no less kind to physicians performing physical therapy - in 2002, the OIG found that 91 percent of PT billed by physicians and allowed by Medicare did not meet Medicare guidelines which resulted in $136 million in improper payments.

Physical therapists aren't off the hook either - reports of individual physical therapists receiving inappropriate payments from Medicare in Texas and Florida have surfaced recently.

What can provider do to show need skill and progress?

When writing your notes, try to answer these questions:
  1. Why are you treating this patient?
  2. How much do you expect them to improve?
  3. How long will it take?
  4. How much will it cost?
  5. What factors (eg: co-morbidities, compliance, family or social issues) may delay or prevent you from meeting these goals?
An excellent tool that can help you answer questions #1,#2 and #3 is a baseline self-report questionnaire.

For example, the Neck Disability Index (NDI), developed by a chiropractor, is a simple, cost-effective tool to show medical necessity and, applied over time,  progress.

A complete literature review on the NDI is available in the May 2009 Journal of the Orthopedic and Sports Physical Therapy Association.

Chiropractors treating Medicare patients may need to learn new techniques and gain new tools for developing a Medicare plan of care for rehabilitation.

One of the specific requirements from the OIG report is the development of a chiropractic treatment plan for each patient that...
  • includes a recommended level of care
  • specific treatment goals
  • and objective measures to evaluate treatment effectiveness

The tools needed to measure treatment effectiveness exist, on the sidebar of this blog, and elsewhere.

For a free e-mail tutorial on writing Bulletproof treatment notes using free, public domain tools, like the NDI, sign up below.

Free Tutorial

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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.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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