"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

Tuesday, January 5, 2010

Is Skilled Maintenance Therapy for Safety the future of Physical Therapy?

You can be audited by Medicare for providing exercise therapy to a aged person whose legs are 'feeble and unstable'.

They need you.

You're getting them better.

But, your therapy is not 'skilled' and you can't get paid - is that fair?

Skilled Maintenance Therapy for Safety refers to a fairly specific clinical scenario: one wherein the specific techniques may not require ongoing performance and assessment by the physical therapist.

Routine strengthening exercises may not require ongoing performance and assessment by the PT.

Skilled Maintenance Therapy for Safety is new to the Florida Local Coverage Determination for Therapy and Rehabilitative Services. (2/12/2009)

Skilled Maintenance Therapy for Safety Clinical Scenario
(found in the Medicare Benefit Policy Manual, Chapter 15).

"Where there is an unhealed, unstable fracture, which requires regular exercise to maintain function until the fracture heals, the skills of a therapist would be needed to ensure that the fractured extremity is maintained in proper position and alignment during maintenance range of motion exercises."
A similar case could be made for the large rotator cuff tear under the care of a conservative orthopedic surgeon. A simple therapy protocol often looks like this:
  • 1st 6 weeks - PROM only
  • 7th-8th week - AAROM only, no shoulder strengthening
  • 9th-11th week - AROM only, no shoulder strengthening
  • 12th week - begin shoulder strengthening
Is this the future?

How could skilled maintenance therapy for safety ever be good for physical therapists?

In 2010, physical therapists are still bound by silly 'process measures' that mandate 'how' we provide 'skilled therapy':
  • -kx modifier
  • 8-minute rule
  • CPT automatic code edits
  • physician certification of the plan of care
  • 90 day re-certifications
  • discharge notes
These rules stifle creativity and innovation in the clinic. Most of the innovation in physical therapy today is happening in academics, not in the clinic.

Instead of these limited clinical examples consider a patient at risk for falling down - a high proportion of the geriatric population (prevalance: 27-30%).

How might we treat them? Three times per week for four weeks?

Or, intermittently, with no set discharge date?

Shouldn't we get paid to prevent falls, rather than treat the aftermath of the fall?

The Florida LCD (p.22) states the following would raise red flags for a Medicare audit if they were included in a Medicare plan of care.
"...repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking, such as that provided in support for feeble and unstable patients"
Get paid to think like doctors think

There now exists a definite body of literature in support of a 'quantitative approach' to assessing future falls risk.

Factors that predict falls are easily measured and interventions readily assigned. The exercises and functional techniques, after a brief training period, are not that difficult or strenuous. The specific exercises may be repetitive but the quantitative risk assessment (performed weekly) is skilled.

The 'skilled' component is the assessment of future falls risk. The exercises or neuromotor training may NOT be skilled after a short training period. These become repetitive in nature - maintenance.

It's like the dental model. Most of the time I see the hygenist for the cleaning, prophylaxis and exam - the dentist is called in for complex conditions.

I would also recommend the examination of the whole patient - the 'Regional Interdependence Model' - looking for risk factors for adverse events other than falls:

Dysfunction and/or presentationTest
rotator cuff weaknessSidelying ER Test
cervical instabilitySupine DCF Endurance
untreated episodic vertigo of peripheral origin (BPPV)history
stiff hipProne Hip IR (bubble inc.)
high risk populations like adolescent females playing volleyball and soccerhistory
post-partum females with 1st episode LBPhistory

Because physical therapists are not dentists we have to document our skilled services - so I designed a template to quantify and record the risk.

The template is available here - along with withering criticism and commentary by physical therapists on the front line of patient care - like you.

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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