"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

Thursday, June 21, 2012

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 MakingLimitedModerateSignificant
Limited30 minutes30 minutes30 minutes
Moderate31 - 45 minutes31 - 45 minutes31 - 45 minutes
Significant45 minutes45 minutes45 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."

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.

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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.
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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.