An Open Letter to Florida Medicare (First Coast Service Options)

This author's continued investigation into the new Medicare policy of Skilled Maintenance Therapy for Safety will be published on this blog for your edification and comment.

The following letter was sent to medical.policy@fcso.com after the normal FCSO Medicare customer service reps were stymied by my questions.

Dear Medicare Policymakers,

The new (2/2/09) LCD for Therapy & Rehab Part B services (L29289) has new instructions for physical therapists (page 21):

Skilled MAINTENANCE THERAPY for Safety

"If the services required to maintain function involve the use of complex and sophisticated therapy procedures, the judgment and skill of a therapist may be necessary for the safe and effective delivery of such services.

When the patient’s safety is at risk, those reasonable and necessary services shall be covered even if the skills of a therapist are not ordinarily needed to carry out the activities preformed as part of the maintenance program."

However, the LCD goes on to clarify the clinical situation:

"It is not medically necessary for a therapist to perform or supervise maintenance programs that do not require
the professional skills of a therapist.

These situations include...
· repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking, such as that
provided in support for feeble and unstable patients;"

The most likely clinical scenario in outpatient physical therapy clinics is when the PT assess a patient likely to fall (complex and sophisticated services = skilled) on a patient whose exercises are necessarily low-level and repetitive (for feeble and unstable patients).

On the face of it, the new LCD language appears contradictory.

I wonder if you could provide some guidance?

Thank you.

Tim Richardson, PT

Merry Christmas from First Coast Service Options

Physical therapists have been given the 'gift' of maintenance therapy on some patients.

This 'gift' comes wrapped in bureaucratic gobbledeegook but is still an improvement over the dogmatic, no-way, no-how ban on maintenance therapy paid by Medicare that existed prior to February 2, 2009. (note: the FCSO primary geographic jurisdiction is only in the state of Florida)

Skilled Maintenance Therapy for Safety

The specific reference is located on pages 21-22 of the FCSO Local Coverage Determination.

I'll give you an example of the garbled way in which Medicare makes known it's intent:

"If the services required to maintain function involve the use of complex and sophisticated therapy procedures, the judgment and skill of a therapist may be necessary for the safe and effective delivery of such services.

When the patient’s safety is at risk, those reasonable and necessary services shall be covered even if the skills of a therapist are not ordinarily needed to carry out the activities preformed as part of the maintenance program."

The most obvious example in outpatient PT would have us treating patients at risk for, say, falling down in the home - even if the interventions might be construed as low level, 'unskilled' treatments.

However, the LCD goes on to say:

"It is not medically necessary for a therapist to perform or supervise maintenance programs that do not require the professional skills of a therapist.

These situations include: (among others)...repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking, such as that provided in support for feeble and unstable patients."

The LCD seems to contradict itself: If assessment of falls risk is "complex and sophisticated" then they are skilled.

If strengthening/confidence building exercises to prevent falls could be construed as maintenance, then these services seem to fit the new definition of 'Skilled Maintenance Therapy for Safety'.

It even seems appropriate to set goals for these 'feeble and unstable' patients such as 'No reported falls in 30 days' to measure the impact of our intervention.

Come to think of it, if I've assessed falls risk, constructed goals, designed an exercise plan of care and attempted to measure the impact then maybe I should just treat these people.

Does anybody else read this LCD the way I do?

Maybe next year I'll ask Santa for the gift of gobbledeegook.

Sugar, Fat and Physical Therapy

Can diet affect physical therapy outcomes?

Does the typical 'American diet' - high fat, high sugar - lead to the expression of anxiety-related behaviors?

University of South Florida researcher David Diamond, PhD recently found that a high carbohydrate/high fat diet caused 'avoidance behaviors' and anxiety among rats.

Dr. Diamond presented his findings at the Society of Neuroscience meeting in Chicago in November 2009.

Dr. Diamond concluded:

"This work indicates that the combination of high fat and sugar diets, as is found in typical American foods such as donuts, cheeseburgers and french fries, not only contributes to obesity, but may also contribute to the development of anxiety disorders."

He has also published studies on the link among high fat diets, chronic stress and the development of anxiety.

Now, I know you don't treat rats (not even the animal physical therapists!) but the effect of diet on mood and affect may have implications for physical therapy treatments - on humans.

I wonder if diet affects physical therapy outcomes?

Fear Avoidance Behaviors (FAB) may be the largest single, measurable factors leading to disability in people with musculoskeletal disorders seen in physical therapy clinics.

Fear-Avoidance Behaviors may explain why some people recover from their acute episode but never regain their full function and eventually go on to suffer recurrences of pain and disability - consuming greater and greater amounts of health services during their lives.

The 1987 Volvo Award in Clinical Medicine went went to Dr. Gordon Waddell of Scotland for his work in quantifying a test (Waddell's Signs) that proposed to assess 'illness behaviour' in orthopedic patients.

Dr. Waddell's 'illness behavior' was described in his award-winning study: A New Clinical Model for the Treatment of Low Back Pain.

'Illness behavior' morphed into the Fear-Avoidance Model that may explain from 15-30% of the variance in rehabilitative outcomes - the largest single factor physical therapists can modify in our patients.

Waddell's signs have since proved to be more 'common sense' than statistically predictive (Waddell's Signs have a positive Likelihood Ratio of 1.7).

Dr. Waddell, however, explained that:

...pathoanatomy does not correlate with pain and this is why we must take a functional approach.
The treatment goal is not pain relief but disability prevention.

The Fear-Avoidance Model improves physical therapists' diagnoses by shifting the emphasis during examination away from patho-anatomy and towards psychosocial stressors consistent with the Biopsychosocial Model.

Dr. Diamond's rats fed the 'American diet' exhibited 'stronger evidence of fear memories' and more fear on tests of memory and anxiety.

Physical therapists can modify or reduce Fear-Avoidance Behaviors by the use of:

"...effective brief psycho-educational strategies that can address the cognitive and affective processes that motivate pain-related activity avoidance."

Should we try to improve our patients' functional outcomes by providing advice on their diet?

RACs Get Complex

Up until now, Recovery Audit Contractors (RACs) have only been approved to issue demand letters for multiple, untimed codes:

• evaluation (97001)
• re-eval (97002)
• e-stim (G0283)
• traction (97012)
• etc

...per day per patient.

The RACs would review your billing profile using computerized, 'data drilling robots' that spot these un-listed Common Procedural Terminology (CPT) code edits and send you a demand letter.

The demand letter would arrive, automatically generated, with days, patients and dollar amounts listed.

Since multiple untimed codes are 'technical denials' there is no appeal.

Now, RACs are approved for complex review - that means they can request and review copies of your charts. They will attempt to find issues that would give basis for a medical necessity denial.

You can appeal medical necessity denials - and you should.

There is evidence that RACs inappropriately interpret published Medicare guidelines in making their denials.

For my state, Florida, Connolly Healthcare is the CMS-approved RAC. Connolly also administers the RAC program for Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.

For Physical Therapists: How NOT to think like a turkey

Do you want to avoid thinking like a turkey?

To NOT think like a turkey, first consider HOW turkey's think...

It's the day after Thanksgiving and a newly hatched turkey has arrived.

He has the coop to himself with plenty of room and no competition for food, etc.

Then, some humans arrive at feeding time. They provide food and water.

After that, they turn the lights down low, turn up the bed warmers and play some soft music.

"My," observes the turkey, "these humans must really love me - they must really be my friends!"

The turkey observes this same process for 364 more days.

Each day is an independent observation that seems to confirm the initial observation - that humans are friendly benefactors of turkeys and would never do anything to harm a turkey.

Then comes Thanksgiving Day and the humans arrive at feeding time - only instead of food they carry hatchets and axes.

"I wonder what those are for?" thinks the turkey.

Needless to say, the turkey dies with a very surprised look on his face.

The Outcome is Dinner

Now, what did the turkey do wrong?

How could the turkey have come to a different conclusion about humans presented with the same set of facts?

What could the turkey have done differently to change the outcome?

The Fallacy of Inductive Logic

The turkey committed the fallacy of inductive logic, first described in 1748 by David Hume, a Scottish philosopher, economist and historian.

Hume's contribution to empirical thought is an important cornerstone of the scientific method and to evidence-based medicine.

"Inductive inference is reasoning from the observed behaviour of objects to their behaviour when unobserved...it is a question of how things behave when they go (in Hume's words)...

"beyond the present testimony of the senses, and the records of our memory."

...we tend to believe that things behave in a regular manner; i.e., that patterns in the behaviour of objects will persist into the future..."

Hume's story uses chickens, not turkeys.

I have adapted Hume's story because turkeys resonate with Americans at this time of the year (Thanksgiving/Christmas).

Turkeys, chickens, David Hume and physical therapists are all searching for one universal constant - the TRUTH.

How can we find it?

For the physical therapist, TRUTH is the answer to these questions:

• What treatment will make my patient better?
• How long will the treatment take?
• How much better will my patient get?
• How much will the treatment cost?

In Hume's time the problem of induction was seen as a barrier to finding the truth. In other words, inductive reasoning (thinking like turkeys/chickens) did not seem to be the path to secular enlightenment (ie: the TRUTH).

Today, the foundation of the scientific method is hypothesis formation, usually by inductive reasoning.

The hypothetico-deductive model (thinking like physicians think) uses inductive reasoning to generate the initial hypothesis, and then to test the hypothesis:

1. Experience: What previous treatments have worked?


2. Why did the previous treatments work? What patient characteristics are unique to the responders (note: this example specifically describes Treatment Based Classification, or TBC).


3. Identify the patient characteristics (from the history or physical exam) that best predict which treatments worked (the outcome).


4. Test your theory.

What could the turkey have done different?

Find one human that likes to eat turkey. Then, the turkey could change his behavior to change the outcome (on Thanksgiving Day, run like hell).

In science, we question our assumptions - we test our theories and we learn from our failures. We're skeptics.

In physical therapy, we call this reflection.

Can PTs make BETTER decisions than physicians?

This International Classification on Functioning (ICF) video describes the unifying framework between the physician and the physical therapy frameworks by Gerold Stucki, MD at the University of Sydney in July 2009.

The link to the video can be found within the World Confederation on Physical Therapy (WCF) December newsletter.
Leaders in rehabilitation research aim to unify the Medical model (eg: pathology) with the Biopsychosocial model (eg: functioning).

The ICF is to be the unifying framework that provides a 'common understanding and dictionary of functioning'.

Imagine a physician asking you for the physical therapy diagnosis for a particular patient.

How would you respond?

What treatment recommendations would you make?

On what would you base your decisions?

What measurements justify your decisions?

Can you make decisions better than physicians?

The RAC Demand Letter No Physical Therapist EVER wants to get

Save yourself some time and money.

Take this sample RAC demand letter to your physical therapist in private practice (PTPP) office manager and let them know this is TOP PRIORITY - if you get a demand for return of overpayment you have 15 days to respond.



That's 15 days from the date in the upper left hand corner of the demand letter - not the date you find the letter in your mailbox. Here is the 4-page .pdf for download.

Why the rush?

According to Belinda Holmes, CPC/CCP of Kerkering/Barberio, an accounting and medical audit firm in Sarasota Florida, many demand letters wind up in the back office, on a 'to do' pile for several days before any action is taken.

Often, the person opening the mail is not even aware of the seriousness and potential financial liability of an automated RAC audit to a PTPP.

Offsets start on Day 41

Offsets are a 'bubble' in your Medicare cash flow pipeline. Offsets take money you would ordinarily collect in your bi-weekly Medicare check. The offset will continue until the entire amount of the overpayment is satisfied.

The demand letter has instructions for appeal - you should appeal since there is evidence that Medicare Recovery Audit Contractors are inappropriately interpreting Medicare guidelines.

Connolly Healthcare is the Florida RAC. They are only auditing automatic edits of PT un-timed codes in 2009,like...

• 97001 (PT evaluation),
• 97002 (PT re-evaluation),
• 971012 (Traction),
• etc (get the full list here).

In 2010 (almost here!), RACs may begin complex medical reviews of providers like PTPPs which means...

• requests for medical records,
• chart reviews and
• denials based on medical necessity,
• skilled physical therapy,
• insufficient documentation,
• no documentation,
• etc.

As I've said, the RACs currently only perform automatic edits on PT un-timed codes.