"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."
Medicare has begun to deny hospital charges for total joint replacement surgery IF the surgeon has failed to implement up to 12 weeks of pre-operative PT and/or bracing, according to Vincent Hudson, CEO of the medical consulting practice PMC, Inc.
"Medicare A has denied payment to hospitals, and I am sure will trickle over to physicians.
This new standard should be increasing the numbers of referrals we see from Medicare.
As in most cases, I expect to see other commercial insurances to follow shortly.
Make your referring physicians aware of this, as hospitals have already begun to do so..."
Vincent made his comments on March 20th on LinkedIn in the Physical Therapists in Private Practice group.
This agressive new program in Medicare Audits is threatening physician and hospital reimbursement for total joint replacements and lumbar spine fusion in many states across the country.
The expanded use of Medicare Administrator Contractor (MAC) pre-payment audits has placed a premium on documentation in the hospital record and may threaten reimbursement for physicians with poor documentation skills.
On November 15, 2011, CMS announced three new 3-year demonstration projects (reported here by PTD). The Recovery Audit Prepayment Review Demonstration is designed to help curb improper Medicare and Medicaid payments.
As proposed, the demonstration would allow Medicare recovery auditors to review claims after services are provided but before the claims are paid to ensure that the provider complied with all Medicare payment rules. This would prevent improper payments before they are made.
Seven states with high populations of fraud- and error-prone providers are targeted
Florida
California
Michigan
Texas
New York
Louisiana
Illinois
...and four states with high claims volumes of short inpatient hospital stays are targeted.
Pennsylvania
Ohio
North Carolina
Missouri
As designed, this program would affect almost half of the Medicare population.
The contractor for MAC jurisdiction 9 is First Coast Service Options (FCSO), which includes Florida, Puerto Rico, and the Virgin Islands. FCSO developed a local coverage determination (LCD) on total joint replacements.
The original draft LCD included a requirement that multiple 12-week nonsurgical interventions, such as physical therapy, be documented prior to surgical total joint replacement.
Revisions to the LCD now require only one non-surgical intervention, such as 12 weeks of physical therapy.
Weeks later, the MAC announced a new prepayment audit of 15 specific DRGs, 4 of which are orthopaedic codes, including those that cover total joint replacements.
"As with the Total Knee replacement, the medical record documentation must indicate continued symptoms following medication ....there also must be documentation of a trial of physical therapy and/or external joint support provided equal to or greater than 12 weeks..."
I agree with Vincent.
Get out there and educate your physicians, especially your family practice docs and your unaffiliated orthopedic surgeons who will want to avoid denials.
Drugs used to treat common, high-volume conditions may become available over the internet and dispensed through your local pharmacy rather than in your doctor's office.
These conditions include:
high cholesterol
high blood pressure
migraine headaches
asthma
"We’re seeing the democratization of information that used to be narrowly held by doctors,”
The Federal Register reported notice of Food and Drug Administration (FDA) meetings Thursday and Friday, March 22 and 23, to get input on a proposal to allow consumers to purchase certain prescription drugs without a doctor's prescription.
Specific, enabling technology (as discussed on this blog) will allow consumers to self-diagnose more and more conditions in healthcare.
"FDA is aware that industry is developing new technologies that consumers could use to self-screen for a particular disease or condition and determine whether a particular medication is appropriate for them.
For example, kiosks or other technological aids in pharmacies or on the Internet could lead consumers through an algorithm for a particular drug product.
Such an algorithm could consist of a series of questions that help consumers properly self-diagnose certain medical conditions, or determine whether specific medication warnings contraindicate their use of a drug product."
The value of clinical prediction rules, or algorithms, are to make clinical decisions explicit and transparent.
Transparent decision making, such as with clinical decision rules, is most useful for 3 stakeholders in healthcare:
Students who need to quickly learn new diagnostic classifications of patients.
Expert decision makers who need to quickly treat patients with unfamiliar or complex patient presentations.
Payers, who need to quickly process claims so they know what they are paying for.
Ultimately, the trend in "patient centered care" will be to create clinical prediction rules that PATIENTS can use to select their care, or their caregiver.
Can anyone imagine that enabling technologies may help patients select physical therapy treatments?
Please contact Governor Rick Scott and request that he sign into law HB 799 by Rep. Tom Goodson and Senator Bill Montford, regarding temporary license for the practice of physical therapy.
Current Situation: The House of Representatives and Florida Senate passed HB 799 unanimously on Friday, March 9, 2012.
The Legislation is now headed to Governor Rick Scott for final action to be signed into law. On behalf of the FPTA, please begin contacting Governor Rick Scott and request that he Sign HB 799 into law.
The Problem: Due to national testing procedure changes adopted in 2011, the physical therapy exam in Florida is only given a limited number of times (3-5) each year and the seats are limited. Due to the change in testing procedures at the national level, Florida Physical Therapy Program graduates may wait three to four months after graduation to sit for the exam. This has created a backlog of graduates waiting to take the exam.
Further, as twenty-four jurisdictions currently offer temporary licenses and permits, graduates of Florida schools are being enticed to leave the state to obtain immediate employment elsewhere in these high demand physical therapy provider positions.
The Solution: The unanimous passage of HB 799, by Rep. Goodson and Sen., Montford amends chapter 486, Florida Statutes, to allow Physical Therapy Program graduates of accredited programs, who are waiting to take the exam after graduation, to work under a temporary license permit. The legislation will also grant a similar license to physical therapist assistant graduates. Again, they would work under the direct supervision of a physical therapist. Similarly, if the exam is passed, they may continue working but cannot continue if the exam is failed.
Both temporary permit licenses are intended to help put graduates to work immediately in a profession that is in demand to serve our aging state population and to retain the graduates from our Florida institutions. The direct supervision relationship is already well established during final clinical education internships.
The Florida Department of Health, Division of Medical Quality Assurance, Florida Board of Physical Therapy, has reviewed this legislative proposal and supports authorization for the physical therapy and physical therapy assistant temporary permit licensees.
The Florida Medical Association has reviewed the bill and has no objection.
Accredited Physical Therapy Schools in Florida (Doctor of Physical Therapy)
Florida Agricultural and Mechanical University
Tallahassee
Florida Gulf Coast University
Ft. Myers
Florida International University
Miami
Nova Southeastern University
Ft. Lauderdale - Davie & Tampa
University of Central Florida - Orlando
University of Florida - Gainesville
University of Miami - Miami
University of North Florida - Jacksonville
University of South Florida - Tampa
University of St Augustine for Health Sciences - St. Augustine
Accredited Physical Therapist Assistant Schools in Florida
Broward College - Coconut Creek
Keiser University - Sarasota
College of Central Florida - Ocala
Miami Dade College - Miami
Daytona State College - Daytona Beach
Pensacola State College - Pensacola
Florida Gateway College - Lake City
Polk State College - Winter Haven
Florida State College at Jacksonville - Jacksonville
St. Petersburg College - St. Petersburg
Gulf Coast State College - Panama City
State College of Florida - Bradenton
Herzing University - Winter Park
South University - Tampa
Indian River State College - Ft. Pierce
South University - Royal Palm Beach
Keiser University - Ft. Lauderdale
Seminole State College of Florida - Altamonte Springs
Action Needed: FPTA leadership and Government Affairs Committee team members request you immediately begin contact Governor Rick Scott and ask him to sign HB 799.
Please accept this letter on behalf of myself and the nearly 5,000 practicing physical therapists, physical therapist assistants, and students in training who are members of the Florida Physical Therapy Association as a request that you sign into law HB 799 by Representative Tom Goodson, and Senate sponsor, Senator Bill Montford, regarding a temporary license for the practice of physical therapy.
The temporary license legislation would create a non-renewable temporary license valid for six months for recent graduates of accredited physical therapy schools. This will allow students from the schools of physical therapy in Florida to continue their on-the-job training, just as they trained as interns before graduation.
Much of the need for this legislation was generated by the fact that the Department no longer administers its own examination, but instead utilizes the national examination to demonstrate competency for physical therapy licensure. As such, graduates can wait up to three or four months before being allowed to sit for the examination, which is administered as few times as three per year, and will soon be offered up to five times per year.
The bill requires strict supervision on site by a licensed physical therapist and no physical therapist may supervise more than one temporary licensee at a time. The bill also provides physical therapy assistant graduates may receive a temporary license while, again, awaiting their opportunity to take the examination.
The Association believes that there are sufficient safeguards built into this law to protect the public while at the same time allowing the physical therapy grads to remain in Florida and be put to work serving clients who need physical therapy services. The legislation allows students the opportunity to begin their physical therapy practice in Florida without having to move to other states that currently allow temporary physical therapy practice.
In addition, the Department of Health Medical Quality Assurance Board of Physical Therapy supported establishment of temporary license. As the population of Florida ages, the need for physical therapy will continue to grow and the State must do everything it can to keep graduates of accredited institutions at home and working in Florida.
It is respectfully requested that you sign this legislation into law.
Florida's Medicare Admistrative Contractor (MAC) First Coast Service Options (FCSO) has identified excessive use of the KX modifier on claims submitted by providers billing outpatient therapy services.
Medicare only reimburses for services that are considered to be reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.
Medicare does not cover maintenance therapy.
The webinar on the Therapy cap exception process and use of the KX modifier will be held on Tuesday, May 22 at 11:30 AM-12:30 PM EST. The delivery language is English.
Are you the person responsible for billing outpatient therapy services for your provider?
Are you a physician, non-physician practitioner, or qualified therapist performing outpatient therapy services for Medicare beneficiaries?
Do you know how to determine if the beneficiary qualifies for the automatic exception process?
Are you or your billing company appending the KX modifier to all therapy claims?
Did you know that excessive use and abuse of the KX modifier could result in a probe review of your practice?
If you've answered yes to any of these questions, then you’ll want to mark your calendars.
You do not want to miss this opportunity to learn valuable information about how and when it is appropriate to use the KX modifier on outpatient therapy claims.
During this free one hour educational event, you'll have the opportunity to learn more about:
Results of data analysis and excessive use of the KX modifier
The financial limitations of the therapy caps
The automatic exception process and when it’s appropriate
How to comply with Medicare regulations regarding the exception process
How to determine if the Medicare beneficiary meets the criteria for the exception process
How to take advantage of self-service tools that can help you make the most of your valuable time
Do you want answers to the questions you have?
To submit your questions in advance of the webcast, just sign-up for the webcast on FCSO University ; select the hyperlink under “Course Activities” and submit your questions.
Please submit your questions no later than May 8.
You can't afford to miss this valuable opportunity to learn and interact directly with your Medicare experts at FCSO.
To participate in this webcast, please register by Monday, May 21.
This program has the prior approval of the American Academy of Professional Coders (AAPC) for 1.0 continuing education unit (CEU).
Granting of prior approval in no way constitutes endorsement by the AAPC of the program content or the program sponsor.
Please click here for CEU documentation instructions.
Register now.
Note: If you do not have a training account, please click here to learn how to create one.
"Practically every EHR in existence today is based on Dr. Lawrence Weed’s SOAP note format...with the singular purpose of speeding up documentation and ensuring that the finished note is a proper clinical, legal and financial document. And as most of us know only too well, we are not there yet."
However, the time for the SOAP note in adult ambulatory physical therapy clinics is over.
The congruence of Electronic Medical Records (EMR)and changing healthcare processes present a once-in-a-lifetime opportunity to improve a paradigm that, in most physical therapy settings, is akin to shoving a square peg into a round hole.
Most of the over 900 EMRs currently in the commercial and federal marketplace use some version of the SOAP format.
Yet, SOAP was originally developed for medical sub-specialty physicians working within the high-cost, acute care hospital to "talk" to one another in an asynchonous fashion.
Asynchronous just refers to the fact that one physician didn't have to actually speak to the other, they could just read each others standardized SOAP notes.
Today, the "killer app" of asynchronous communication is called e-mail.
The birthday of SOAP is convenient in the context of this discussion begun March 16, 2012 on the technological value of paper vs. Electronic Medical Records (EMR) records from the EMR and HIPAA blog called Paper Has Healthcare Spoiled.
The above video, also from the EMR & HIPAA blog, skewers the traditional technology Help Desk that requries every computer/EMR user to need a Help Desk. Healthcare should be easier that this.
SOAP is part of the problem because physical therapists, most of whom practice outside the acute hospital setting, are forced into using the SOAP format.
Most PTs still use SOAP written on paper.
According to the EMR and HIPAA blog:
Paper is...
"Flexible to an infinite number of documentation methods.
Does paper support the SOAP format? Yes!
Does paper support every specialty? Yes!
Paper has the ability to morph to every medical specialty’s documentation needs."
While paper has certain, underappreciated, technological virtues SOAP is vulnerable to criticism as a documentation format, especially for chronic health conditions.
SOAP encourages a clinical record that is...
Described from the provider’s perspective only
Brief and vague
Focused on the patient’s immediate painful symptoms
Focused on the provider’s particular treatment
Repetitive
Narrative, rather than data driven
SOAP does NOT fulfill its mission for chronic health conditions seen in the ambulatory PT setting.
SOAP's appeal lies in its universal acceptance rather than its ability to describe the patient experience.
"Trained in the ... ability to write (which) is near universal thanks to training in doing so since we were children."
We should use the convergence of electronic tools and medical documentation as an opportunity. An opportunity not just to decrease paper medical records but also to change the SOAP format and start over using modern tools to describe disabling conditions experienced by our patients.
I bet physical therapists could come up with some good ideas.
Home health agencies submitted 22 percent of claims in error for unnecessary medical services or for incorrect coding in 2008.
That adds up to $432 million in improper Medicare payments, according to an Office of Inspector General (OIG) report released Tuesday.
Of those, home health agencies upcoded about 10 percent ($278 million) of claims.
Home health agencies did not submit required Outcome and Assessment Information Set (OASIS) data for 6 percent of the claims in 2009, which represented more than $1 billion in Medicare payments, according to another OIG report.
Read Fierce Healthcare's report on Home Health care fraud and abuse here.
Get the March 2012 Office of the Inspector General Report (OIG) report on Home Health fraud and abuse here.
Why One-Third of Hospitals Will Close By 2020, written by by David Houle and Jonathan Fleece, JD, on the KevinMD website is a thought provoking and timely for private practice physical therapists.
Jonathan Fleece is my hometown healthcare attorney in Bradenton, Florida.
His firm, Blalock Walters, has helped out the Florida Physical Therapists in Private Practice (FLPTPP) by providing Michael Magidson, Esq. to speak on Medicare Accountable Care Organizations (ACO) at our inaugural convention in August 2011 in Orlando.
Jonathan's new book, The New Health Age: The Future of Health Care in America should be required reading for private practice clinicians who want to remain competitive and profitable in 2020.
Services billed by physician specialties represented 70% of the dollars incorrectly paid for physical therapy services in the November 2011 Comprehensive Error Rate Testing (CERT) Report.
Additionally, past medical review experience has identified high claim error rates when therapy services are billed by physicians.
The most common reasons for an error to be assigned are the following:
insufficient documentation
failure to meet Medicare’s documentation requirements specific to physical therapy services
failure to meet medical necessity guidelines.
Therefore, based on high error rates validated through CERT findings and FCSO’s data analysis, a prepayment medical review edit for physical therapy claims billed by physicians in Florida will be implemented on March 19, 2012.
This prepayment edit will require submission of medical records to support physical therapy services billed by physicians.
Just one day after the Health Affairs article that showed an association between physicians' Electronic Health Record (EHR) use and increased ordering of diagnostic imaging the chief of the Office of the National Coordinator for Health Information Technology (ONC HIT), Dr. Farzad Mostashari has writen a scathing piece in the Health IT Buzz blog blasting the author's conclusions as "far beyond the scope of their research".
Dr. Mostashari points out the following:
The Original Study Was Not About EHRs At All, Much Less Their “Meaningful Use”
The Original Study Falls Prey to the Classic Fallacy of Using Association to Suggest Causality
The Original Study Did Not Consider the Appropriateness of Imaging Tests
Reducing Test Orders Is Not the Way that Health IT Is Meant to Reduce Costs
Essentially, Dr. Mostashari is serving as a government mouthpiece trying to poke holes in a study that questions the effectiveness of the 2009 American Recovery and Reinvestment Act (ARRA) that provides $25.8 billion in stimulus funding, much of to physicians and hospitals who purchase Electronic Health Records.
Dr. Ray, one of the commenters to Dr. Mostashari's blog post points out that the burden of proof is on the government to show that EHRs actually work to bring down costs.
And, quoting the original authors:
"History urges caution in assuming that advances in medical technology will result in cost savings. In fact, the opposite is more often the case."
Medical imaging costs will most likely rise as physicians gain increased access to image-viewing features of EHRs.
And, as I originally pointed out, critical pathways for high-cost conditions treated by physical therapists will become increasingly popular, driven by payers frustrated by soaring medical imaging costs.
First Coast Service Options (FCSO) is estimating an improper payment error rate of 39 percent for chiropractic services in J9 (Florida, Puerto Rico and the US Virgin Islands) for the November 2011 CERT report.
These payment errors often involve the billing of chiropractic manipulation services that represent maintenance care.
Providers’ adherence to Medicare coverage guidelines for chiropractic services continues to be a significant issue in Florida, Puerto Rico, the U.S. Virgin Islands, and the nation.
Based on previous national findings, CMS requested that CERT perform a special study of chiropractic services in 2010. The CERT special study on chiropractic services yielded an overall error rate of 86.91 percent for J9.
The vast majority of the services reviewed were denied for insufficient documentation and for not being medically reasonable and necessary.
Aside from documentation issues, the primary reason for payment errors in chiropractic services is maintenance therapy being billed as active treatment. This continues to be an issue, even after CMS implemented an acute treatment modifier to allow providers to differentiate maintenance from active treatment on submitted claims.
To help reduce and prevent improper payment errors, FCSO is reviewing data to identify beneficiaries receiving chiropractic services at routine intervals for extended periods of time and will develop beneficiary specific edits.
FCSO will monitor the appeals data closely for these beneficiary specific edits, allowing ongoing edit adjustment when indicated.
Additional information
FCSO has a Web-based training (WBT) module for chiropractic services available on FCSO University . In addition, helpful information and links to chiropractic services resources can be found on the FCSO provider website and the chiropractic services specialty page.
Also, a local coverage determination (LCD) was developed to assist providers in determining when Medicare will consider chiropractic manipulation of the spine medically reasonable and necessary. The LCD also provides guidance on documentation requirements.
Contrary to the notion that Electronic Health Records (EHR) will lower spending a new study in the March Health Affairs found a 40% to 70% INCREASE in ordering of second x-ray or CAT scan. EHRs are supposed to lower health care spending by improving physician access to a patient's medical history and diagnostic test results.
A "convenience effect" may be the mechanism by which EMRs lead to increased imaging.
Physicians have the ability to review results much more quickly and without having to track them down from an imaging facility.
"The effect may be to provide subtle encouragement to physicians to order more imaging studies".
Referring to better access to results with computerization, lead author Danny McCormick, MD says,
"As with many other things, if you make things easier to do, people will do them more often."
You can also read this summary article from Fierce Healthcare.
One implication for physical therapists might be an increased need for critical pathways like the Starbucks/Virginia Mason model from 2006 or the Intel/Cigna model from 2011 in order to contain the overutilization of diagnostic imaging.
Ezra Klein of the Washington Post blames high prices charged by healthcare providers and hospitals for spiraling costs in America's healthcare system in an article titled Why an MRI costs $1,080 in America and $280 in France.
According to Klein...
"Two of the five most profitable industries in the United States — the pharmaceuticals industry and the medical device industry — sell health care.
With margins of almost 20 percent, they beat out even the financial sector for sheer profitability.
The players sitting across the table from them — the health insurers — are not so profitable.
In 2009, their profit margins were a mere 2.2 percent.
That’s a signal that the sellers have the upper hand over the buyers."
However, health insurers are also doing pretty well.
According to the Boston Globe, Blue Cross Blue Shield of Massachusetts made $136.1 million dollars in 2011 which was TEN TIMES more profit than they made in 2010!
Here is the breakdown of CEO compensation for the four largest health insurance companies in Massachusetts:
Blue Cross CEO Andrew Dreyfus received $874,000, up from $800,000 in 2010.
Tufts CEO James Roosevelt Jr. received $1.7 million, up from $1.2 million in 2010.
Harvard Pilgrim CEO Eric Schultz received $1.2 million, up from $795,000 in 2010.
Fallon CEO W. Patrick Hughes, received $810,000, up from $649,000 in 2010.
“A continuing decline in consumer demand for medical services... had a positive impact on our financial performance.”
So, if I follow the logic - Americans pay health insurance premiums but then they can't afford to obtain medical services (perhaps because co-payments are SO high?) and that's the fault of the the medical provider?
"You shouldn't bend you back when you lift things".
"Don't work too hard".
"Don't go back to the gym until I tell you its safe".
And (drum roll please), the most egregious commission of all - "Consult with your physician BEFORE you begin an exercise program".
Are conventional physical therapists in danger of creating what MovNat founder Ewan Corwin calls "zoo humans"?
Watch this 1:32 video and leave a comment.
Its pretty impressive.
Maybe physical therapists and their patients could learn from two-year old Steven in the video below some tips for confronting their movement limitations.
South Dakota Governor Dennis Daugaard signed House Bill 1183 on February 27th, 2012 protecting physical therapists' patients with legislation promoted by the South Dakota Physical Therapy Association (SDPTA).
The Republican super-majority in both the South Dakota House and Senate limited the amount a health insurer may charge a patient for an out-of-pocket copayment or coinsurance amount when they visit a physical therapist or occupational therapist.
After the bill takes effect on July 1, 2012 those copayment and coinsurance amounts cannot be higher than those charged when a patient visits a primary care physician or practitioner.
"The idea behind HB 1183 is that through reduction of financial barriers to care patients will be better able to access the care they need and focus on getting better," said Ronald Van Dyke, PT, OCS, president of SDPTA.
"We believe it will also save healthcare dollars in the long run by preventing unnecessary delays in care that might allow a patient's problem to worsen, requiring higher-cost services like surgery and prescription medication."
Read the Press Release at the website of the American Physical Therapy Association (APTA).
Now, the flagship trade magazine of the American Physical Therapy Association has picked up the torch in the March 2012 issue of PT in Motion, The Fight for Fair CoPays.
Its worth reading no matter what setting you work in.
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.
"Make Decisions like Doctors" Copyright 2007-2010 by Tim Richardson, PT. No reproduction without authorization.
Share PTD with your Peers!
American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.
