Is the Severity-Intensity Model a Roadmap for Fraud and Abuse?

First, I'd like to thank all the hard-working staff and volunteers at the American Physical Therapy Association (APTA) for the effort that went into developing the Severity-Intensity Model, also known as the Alternative Payment System (APS).

Like them, I'd like to see payment reform. But, I want reform that preserves the autonomy of the therapist-patient collaboration rather than depends on centralized oversight of physical therapists by government regulators.

I'm afraid the Severity-Intensity Model may just increase the ability of regulators to audit physical therapists.

Physical therapists are set-up to fail, in every setting, by a documentation framework that was never intended to capture the patient experience of chronically disabled adults.

The Physical Therapy Business Alliance keyed-in on a central flaw in Severity-Intensity in its post at EIM on June 13th, 2012:

"However, the APS in its current form disproportionately emphasizes administrative and regulatory requirements (ie, documentation, compliance, etc.) at the expense of the most critical elements of the clinical encounter, which is incentivizing quality clinical outcomes and patient satisfaction."

We're not alone - this telling indicator of professional consensus is the OVERWHELMINGLY NEGATIVE comments posted at the PTinMotion web site in response to an article on the Severity-Intensity model.

Severity-Intensity Would Increase "Fraudbusting", not fraud
This chart is derived from the Development Draft for APTA Members: An Alternative Payment System for Physical Therapy Services - APTA members have until Friday, June 22nd to comment.

Go to this link and add your two cents.

Recommended Times for Severity-Intensity Patient Visits
	Patient Severity at the time of the Visit
Intensity of Therapist Decision Making	Limited	Moderate	Significant
Limited	30 minutes	30 minutes	30 minutes
Moderate	31 - 45 minutes	31 - 45 minutes	31 - 45 minutes
Significant	45 minutes	45 minutes	45 minutes

The yellow cells are 1-on-1 codes that require individualized interaction between the qualified healthcare professional and the patient.

We all think OUR patients are more difficult to treat than our fellow therapists' patients - this is true in medicine too and is known as Response Bias (seeing what you expect to find). Therefore, using Severity-Intensity we would expect to see a "southeast shift" in coding based on this chart - every patient belongs in the yellow highlighted cells. 

"Code inflation" would occur, based on coding and reimbusement seminars promoted by "Medicare Experts" - here's an example I received yesterday in my e-mail:

"Treatment consists of manual therapy, 97140, to reduce swelling and scar formation followed by passive, active assistive ROM exercise to improve ROM at the knee; 97110, quad sets, SAQ, and SLR to promote the efficiency of the quad contraction and promote quad control at the knee joint, 97112; and finally, I want to put it all together by working on sit to stand transfers emphasizing knee flexion in sitting and equal weight distribution in sit to stand and stand to sit, 97530."

Really?

Is this what we want Doctors of Physical Therapy spending their time on in the 21st century? Writing this blah-blah-blah?

I think your time, and mine, is more valuable than that.

And, technology is increasingly bringing us better documentation alternatives.

Severity-Intensity just adds a layer of complexity on top of the flawed documentation framework that wastes so much time and physical therapist productivity.

What Now?
The Severity-Intensity Model needs to be accepted by the American Medical Association Relative Value Update Committee (AMA RUC) which may then recommend Severity-Intensity to the Centers for Medicare and Medicaid Services (CMS) to be used within its Current Procedure Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) IN PLACE OF the CPT 92505-97799 codes (also a few G-codes and a few others, possibly).

What Do We Use Instead of Severity-Intensity?
The American Academy of Family Physicians (AAFP) has proposed to the Congress a primary care-based Medical Home Model which pays primary care physicians three ways:

• Fee for Service for each individual procedure
• a care management fee that compensates for expertise and time such as management and care coordination that are not direct patient encounters
• Pay for performance based on hitting benchmarked process and outcome measures

I believe the way forward for physical therapists is to move "upmarket", in the words of disruptive innovator Clayton Christensen, and compete directly with primary care physicians for the care of musculoskeletal conditions.

Physical Therapists Cannot Opt-Out of Medicare

From First Coast Service Options e-news (June 18th, 2012): Private contracts between beneficiaries and physicians or practitioners.

Title 42, Part 405 of the Code of Federal Regulations outlines the guidelines and requirements for physicians and/or non-physician practitioners who wish to enter into private contracts (opt out).

These regulations permit a physician or practitioner to opt out of Medicare and enter into private contracts with Medicare beneficiaries, if specific requirements of these instructions are met.

Definition of physician or practitioner
For purposes of this provision, the term “physician” is limited to doctors of medicine and doctors of osteopathy who are legally authorized to practice medicine and surgery by the state in which such function or action is performed; no other physicians may opt out.

Also, for purposes of this provision, the term “practitioner” means any of the following to the extent that they are legally authorized to practice by the State and otherwise meet Medicare requirements:

• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified registered nurse anesthetist
• Certified nurse midwife
• Clinical psychologist
• Clinical social worker
• Registered dietitian
• Nutrition professional

The opt-out law does not define “physician” to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract.

Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt-out law’s definition of either a “physician” or “practitioner.”

Physical medicine and rehabilitation physicians targeted in probe of therapy services

First Coast Service Options Inc. (FCSO) conducted a widespread probe (WSP) review in response to an aberrant billing pattern for CPT codes and posted this notice June 12th, 2012.

Here are the codes with high error rates:

1. 97032 (Application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes);
2. 97035 (Application of a modality to one or more areas; ultrasound, each 15 minutes)
3. 97124 (Therapeutic procedure, one or more areas, each 15 minutes; massage including effleurage, petrissage and/or tapotement [stroking, compression, percussion]) billed by specialty 25 (physical medicine and rehabilitation).

The results of the widespread probe yielded a 62 percent claim error rate.

The most common reason for an error to be assigned was insufficient documentation including failure to meet Medicare’s documentation requirements specific to therapy services.

As a result of the widespread probe findings, FCSO will implement a prepayment medical review edit for therapy services billed by physical medicine and rehabilitation physicians.

The following is a brief summary of Medicare requirements for therapy services:

1. Therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services.
2. Documentation must be legible, relevant, and sufficient to justify the services billed.
3. The patient receiving outpatient therapy services must be under the care of a physician/nonphysician practitioner (NPP). NPP signifies a physician assistant, clinical nurse specialist or nurse practitioner, who may, if state and local law permit it, and when appropriate rules are followed, provide, certify, or supervise therapy services.
4. Therapy services must relate directly and specifically to a written treatment plan.
5. The plan (also known as a plan of care or plan of treatment) must be established before treatment is started. The plan is established when it is developed (e.g., written or dictated).
6. The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded within the plan.
7. The Plan of Care shall contain, at minimum, the following information as required by regulation (42 CFR 424.24 and 410.61) See Pub. 100-02, Chapter 15, section 220.3 for further documentation requirements).
• Diagnosis
• Long Term treatment goals
• Type, amount, duration and frequency of therapy services
8. The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan.
9. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.
10. Long Term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care in the current setting.
11. When the episode of care is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified.
12. Goals should be measurable and pertain to identified functional impairments.
13. When episodes in the setting are short, measurable goals may not be achievable; documentation should state the clinical reasons progress cannot be shown.
14. The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a description of a specific treatment or intervention.
15. Where a physician/NPP establishes a plan, the plan must specify the type (PT, OT, SLP) of therapy planned.

Various entities may request documentation to support services billed to the Medicare program (e.g., Medicare administrative contractor [MAC], comprehensive error rate testing [CERT], recovery audit contractor [RAC], zone program integrity contractors [ZPIC], or the office of inspector general [OIG]).

Documentation in the Patient's Chart
The following documentation must be submitted in response to a request for documentation, unless the requesting contractor specifies otherwise.

1. Evaluation and plan of care (POC) (may be one or two documents). Include the initial evaluation and any reevaluations relevant to the episode being reviewed; Certification (physician/NPP approval of the plan) and recertification when records are requested after the certification/recertification is due;
2. Progress reports (including discharge notes, if applicable) when records are requested after the reports are due;
3. Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes). Daily treatment notes must indicate the individual modalities performed that day. Minutes must be documented for each modality that represents a time-based code and the total time in treatment must be documented.
4. A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands the reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation. If the patient is expected to exceed the therapy cap, the record must clearly indicate the medical necessity for the patient to receive covered services above the cap. Note: The excessive use of modifier KX (Requirements specified in the medical policy have been met) may indicate abusive billing.

Therapy services have their own benefit under section 1861 of the Social Security Act (“the Act”) and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals. Statute 1862 (a) (20) of the Act requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions -- other than licensing -- that would apply to a therapist.

Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology.

That means that the services of athletic trainers, massage therapists, recreational therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as covered therapy services.

In addition, there is no coverage for services provided “incident to” the service of a therapist. Although physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) work under the supervision of a therapist and their services may be billed by the therapist, their services are covered under the benefit for therapy services and not by the benefit for services “incident to” a physician/NPP. The services furnished by PTAs and OTAs are not incident to the therapist’s services. A physical therapist must supervise PTAs and an occupational therapist must supervise OTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. The service of a PTA and OTA shall not be billed as services “incident to” a physician/NPP’s service, because they do not meet the qualifications of a therapist. Only services provided by a licensed therapist or an individual who has completed an accredited PT or OT curriculum and are qualified for licensure may provide services “incident to” the physician/NPP.

Providers are encouraged to review the complete requirements for billing rehabilitation services found on FCSO’s Therapy and Rehabilitation Services local coverage determination L29399 (Puerto Rico and the U.S. Virgin Islands) as well as the requirements found in the Internet-only manual (IOM), Pub. 100-02 , Medicare Benefit Policy Manual, Chapter 15, Sections 220-230 .

Medicare ACOs Grow 38% in Six Months

Physical Therapists are keenly interested in the possibility of Medicare Accountable Care Organizations (ACO).

Private practice and corporate-owned rehabilitation companies are especially interested since we are not considered ACO Providers - but, we can partner with large physician practices and hospitals to provide therapy services and share in any cost savings.

ACOs have grown 38% in the last six months, according to a new report titled Growth and Dispersion of Accountable Care Organzations: June 1012 Update.

"Located in 45 states and the District of Columbia, ACOs total 221 partnerships, up from 160 ACOs in 40 states in November 2011..."

I think ACOs offer physical therapists an unrivaled opportunity to compete on the basis of:

1. better costs
2. better patient satisfaction
3. better safety
4. and better outcomes

...that's actually about the correct order - cost and satisfaction before safety and outcomes.

Can anyone suggest a better order?

Should Physical Therapists Stop Manipulating the Cervical Spine?

The Chartered Society of Physiotherapy (Great Britain) posted this announcement on June 8, 2012: Stop spinal manipulation for neck pain, warn researchers.

Neil O’Connell, lecturer at Brunel University’s Centre for Research and Rehabilitation, advises physical therapists to warn their patients against cervical spinal manipulation whether from physical therapists, chiropractors or osteopaths.

Mr O'Connell argues that there is consistent evidence of an association between spinal manipulation and tears to the lining of the vertebral artery in the neck, which can cause stroke.

Countering Mr. O'Connell's argument is David Cassidy, a Canadian professor of epidemiology at the University of Toronto.

Professor Cassidy argues there is...

• "...high quality evidence showed that manipulation could clearly benefit patients with neck pain
• that there was no causal link between manipulation and stroke
• and that the treatment should remain as an option for therapists."

Mr. OConnell's full text position paper is here.

Professor Cassidy's full text position paper is here.

Mr. OConnell's British Medical Journal article is here. (subscription required)

Professor Cassidy's British Medical Journal article is here. (subscription required)

Treatment Based Classification: Where Does it Fit In?

A recent webinar from the Healthcare Information Management Systems Society (HiMSS) called Improving Care with Predictive Analytics: The Next Generation of Clinical Decision Support offered this nice schematic of where decision rules fit into the "black box" that we call clinical decision making.

I've circled in red the "Rule Based" decision format used by TBC

CDS = clinical decision support, ANN = artifical neural network

Individual, idiosyncratic clinician decision making is not pictured in this schematic - just computer based.

I'm hopeful that, going forward, that these types of decision support will continue to expand to incorporate more of physical therapist practice.

I believe that handing off some of the automatic functions, such as documentation, will enable physical therapists to spend more time face-to-face with their patients.

My new book, pictured in the upper left hand corner of this page, describes the current state of Clinical Decision Support in  physical therapy and where we can go from here.

Are Patients Protected from Healthcare Algorithms?

Physical therapists are considering algorithms, such as Treatment Based Classification, to help improve patient care.

But, according to this TED talk, algorithms sometimes run amok, conflicting with one another in an endless loop.

Such an endless loop may have caused the 2:45 "Flash Crash" that caused $1 trillion dollars to just disappear



Healthcare algorithms can provide clinical decision support in Electronic Medical Records (EMR).

If they can behave anything like financial algorithms then physical therapists must demand proper protection for patients before using them.

The Future of Physical Therapy

"The future is already here - its just not evenly distributed"

William Gibson's most famous (and over-quoted) quote. He also coined the word cyberspace and won the Triple Crown of science fiction literature: the Nebula award, the Hugo award, and the Philip K. Dick Award for his first novel, Neuromancer.

But, today I want to tell you about some physical therapy writers - or, more accurately, their work.

First, is a new, fascinating article in PT in Motion called Virtual Realities: Visions of Science, Technology, and Physical Therapy - Virtual Realities beyond 2020.

You'll read about...

• augmented reality of stroke patients moving their limbs
• holograms of patients homes
• robots in the clinic
• exoskeletons helping kids walk
• and more...

And, this article I wrote for Advance for Physical Therapy called Future Electronic Medical Records (EMR) Directions that describes...

• video documentation of patient movements
• interoperable patient records in the PT clinic
• smart phones used easily in the PT clinic
• scheduling patients with text messages
• and more...

Its an exciting time to be a physical therapist.

Are you ready for it?

Adverse Reponse to Exercise: Rare or Common?

We just don't know.

This study Adverse Metabolic Response to Regular Exercise: Is It a Rare or Common Occurrence? was reported in PLoS One yesterday (online).

This is the first study like this I've ever seen. According to the study authors:

"Whether there are people who experience adverse changes in cardiovascular and diabetes risk factors has never been addressed."

This just underscores the need for physical therapists to monitor basic, cardiovascular signs in response to exercise.

• Blood pressure
• pulse
• respiratory rate
• oxygen stauration
• rate of perceived effort
• et al

Acocrding to Jette and Jewel in the April 2012 PT Journal:

• only 11% of physical therapists routinely measure blood pressure
• only 38% of physical therapists routinely measure Body Mass Index (BMI)
• only 21% of physical therapists routinely advise patients to quit smoking
• only 29%% of physical therapists routinely complete a neurological examination in diabetic patients
• only 26% of physical therapists routinely complete a footwear examination in diabetic patients
• only 6% of physical therapists routinely measure gait velocity in their older patients

I'd like to see physical therapists advocate to change our state practice acts so that we could penetrate the skin and collect blood samples to measure important factors in assessing exercise response, included in this study:

• fasting plasma HDL-cholesterol (HDL-C)
• triglycerides (TG)
• insulin (FI)

At least one state physical therapists' association was successful in 2011 in increasing their scope of practice to allow penetration of the skin.

But, before changing state practice acts we need to measure the basic stuff.

Otherwise we'll never know.