"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

Wednesday, May 13, 2009

What about Bob?

Heavy metals leech from chemicals used in ‘old style’ print-making processes through the skin and hands of workers and into their blood. The printing process exposed workers not only through their skin but also through the air they breathed – chemicals became aerated through heating and splashing.

Bob Smith retired from printing after thirty years of exposing himself to dozens of potentially toxic heavy metals that could have leeched into his blood and caused his rare nerve disease that weakened his muscles, deadened the sensation in his feet and caused him to stumble and fall.

Bob had a disease called peripheral neuropathy that caused the tips of the nerves in his legs to slowly begin dying. Normally, peripheral neuropathy works its way up the nerves destroying sensation and muscle control – first in the toes and feet and working its way up to the thighs. The nerves normally die in a steady, progressive pattern and should have taken years to fully rob Bob of the function of his legs.

Bob could have expected to learn to adapt slowly to the irreversible loss of muscle strength and tone in his legs following nerve death.

Except Bob didn’t have time.

Bob woke one balmy Florida morning in September 2008 to find the nerves of the left foot and leg dead.

Bob’s doctor gave him the devastating news with some puzzlement since Bob had no symptoms in the right leg. Normally, peripheral neuropathy is evenly distributed across both legs at the same time.

Even more puzzling, three weeks later Bob began to regain some function in the left leg. He could feel his toes again. He could put weight on the left foot and stand on the left leg somewhat. Bob and his wife Joann were ecstatic but the doctors were concerned – peripheral neuropathy doesn’t normally get better.

Perhaps the medical diagnosis was wrong?

By Thanksgiving, Bob was walking with only a lightweight plastic brace on his left foot and planning his holiday travel schedule up North with his family. He finished physical therapy and said goodbye to his therapists. Bob was out of therapy only a couple of weeks when devastation struck again – this time the right leg suddenly gave way and Bob reported numbness and weakness all the way to his right hip.

Bob’s specialist medical doctor was stumped and referred Bob to the Mayo clinic in Jacksonville for a complete work up. Bob’s hope for a new diagnosis was ironically fufilled when the Mayo clinic doctors told him he had TWO types of neuropathy, not just one.

Bob also had neurogenic claudication from lumbar spinal stenosis – in addition to his heavy metal poisoning.

Bob struggled through Christmas and New Year’s and it wasn’t until the beginning of February that his therapists started measuring some return of function in his wasted right leg.

He stopped using the walker and began using a cane. Bob is now making steady progress and his therapists expect more from him. His wife, Joann, is at every therapy session and pushes him as hard as the physical therapists push him. Bob has never willingly missed a therapy session in eight months.

The Moral Imperative

Bob meets all of the basic requirements for physical therapy services:

• Need
• Progress and Expected Improvement
• Skilled Decisions

If anyone should get more physical therapy then Bob should.

But, Bob is also an outlier – his eight months of therapy clearly put him beyond the mean and the median number of visits for a typical outpatient therapy patient in the United States.

The Financial Imperative

Medicare spends about $3.6 billion (2006) on outpatient physical therapy and over $400 billion (2008) for all health care payments in the United States.

Prior to 2006, when annual per beneficiary financial limitations (the ‘therapy caps’) began Medicare costs for outpatient physical therapy were rising at over 35% per year.

These "piles of cash" are vulnerable to exploitation by entrepreneurial physicians, physical therapists and other, business-minded, operators.

Medicare and Medicaid comprise 50 percent of all US government improper payments in fiscal year 2008 (~$36 billion dollars).

The Pinch Point

Physical therapists are in the pinch point because we see cases like Bob’s daily – people who deserve more care but are arbitrarily limited by financial constraints imposed by a beleaguered health care marketplace.

Physical therapists are the decision makers for people like Bob – does Bob get more therapy and get better or does he get to just go home and stagnate? I know one clinic whose policy is to discharge the patient at $1,840, arbitrarily.

Bye bye. Go home.

One Man’s Answer

Here is the solution I propose: the physical therapy Justification Statement for exceeding the Therapy Cap. The following is a proposed template that is also available at BulletproofPT.com in downloadable PDF format.

Justification Statement

Since 1/05/09 Mr. Bob Smith has had 40 visits to physical therapy working on right leg 'peripheral neuropathy' and difficulty walking.

In February, Mr. Smith exceeded his annual, per beneficiary financial limitation ("therapy cap") and we recommend using a "-KX" modifier to demonstrate need and expected improvement.

He has shown measurable progress on the following standardized tools:

Self-report measures

1. Lower Extremity Functional Scale (see chart)
2. Oswestry Disablement Scale
3. OPTIMAL Scale

Performance measures

1. Functional Reach Test (see chart)
2. Berg Balance Scale
3. Timed Up and Go Test
4. Single Leg Support Test
5. Rhomberg Test

Impairment measures

1. Supine SLR (see chart)
2. Quadriceps MMT (sitting)
3. Knee Extension AROM (supine)

Additional evidence demonstrating progress and expected future improvement includes the following:

1. Bob decreased his assistive device from a walker to a 4-point quad cane over community distances.

2. His written statement, signed by Bob Smith and his wife, affirms his progressive independence in dressing, grooming and bathing at home. They both desire for Mr. Smith to continue working in physical therapy in order to attain full independence.

3. In 2008, Mr. Smith's left leg recovered from sudden onset 'peripheral neuropathy'. He had a short course of physical therapy and uses the left leg now for walking.

If you are like me and you occasionally get patients like Bob then you need a justification statement. Here is the Medicare reference (p.24) speaking to the need for a separate statement, apart from your PT notes. Use mine. Make your own.

Either way, don't send people like Bob home without their physical therapy.

Bob needs more time.

Free Tutorial

Get free stuff at BulletproofPT.com

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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