"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, October 23, 2012

Maintenance #PhysicalTherapy Paid by Medicare?

This may be the biggest change to Medicare affecting physical therapists since the March 23rd, 2010 passage of the Patient Protection and Affordable Care Act (PPACA).

Medicare may now be forced to adhere to the statutory language enacted by the Congress instead of the more restrictive policies adopted by individual Medicare Administrative Contractors (MACs) who limited therapy services because the patient did not show progress.

In other words, Medicare may now be forced to pay for "Maintenance Therapy".

A proposed settlement announced today at 2pm by the Center for Medicare Advocacy (CMA) will be held in Washington DC. According to the CMA:
"Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for such services if they are needed to 'maintain the patient’s current condition or prevent or slow further deterioration,' regardless of whether the patient’s condition is expected to improve."
Physical therapists have long been told by Medicare Auditors that we must discharge our patients when they "plateau" and their function no longer improves. To be sure, physical therapists shouldn't use today's decision to ignore equally challenging documentation guidelines. Physical therapists still need to show "skilled physical therapy" and "medical necessity for physical therapy". This New York Times article discusses some of the new cost implications to Medicare of maintenance therapy.

However, the CMA has removed a significant barrier to care between physical therapists and their patients.
"For decades, Medicare beneficiaries – particularly those with long-term or debilitating conditions and those who need rehabilitation services – have been denied necessary care based on a so-called “improvement standard.” 

This illegal practice means that Medicare coverage for vital care is denied to thousands of individuals on the grounds that their condition is stable, chronic, not improving, or that the necessary services are for “maintenance only”. 

The Improvement Standard conflicts with the law."
This decision will impact patients and physical therapists in most settings, including the private practice physical therapy clinic, the home health setting, skilled nursing and the hospital outpatient setting.

What do you think? Are you in favor of Medicare paying for maintenance therapy?

Monday, October 22, 2012

Medical Apps for Physical Therapy

Video documentation of the physical therapy note is the future and the iPhone is the logical choice for the clinical handset.

Several apps have been developed that use the camera and video features of mobile devices to record patient function.

I reviewed a mobile app developed in 2011 and my review of this innovative mobile app is featured on the Medical App Journal.

Write me if you'd like to see your medical or physical therapy app reviewed.

Sunday, October 14, 2012

Important reminders before completing the pre-approval of therapy services form

First Coast Service Options' (First Coast’s) Medical Review department is returning a high volume of pre-approval requests for therapy services forms due to inaccurate, incomplete, or invalid information. Requests that are returned will not be processed. Corrections must be completed and a new request submitted.

The following list has been developed to assist you in avoiding this situation. These are some things you should check for before faxing or mailing your form:

  • Verify that you are submitting the pre-approval request during your appropriate phase. Pre-approvals may not be submitted earlier than 15 days prior to the beginning of your applicable phase. 
  • Do not send in documentation without the completed pre-approval request form. 
  • Do not use your own coversheet when faxing the pre-approval form. The completed pre-approval form will serve as your coversheet. 
  • Do not split a single request into multiple faxes. All documentation for a single pre-approval request must be submitted together. 
  • Do not submit duplicate requests. Physical therapy (PT), occupational therapy (OT), or speech language pathology (SLP) must be checked on the pre-approval form to indicate the therapy discipline that the additional days are being requested for. If a patient is receiving multiple disciplines (e.g., OT, PT) that you are requesting additional therapy days for, two separate requests must be submitted. 
  • Provide the correct provider transaction access number (PTAN) and/or national provider identifier (NPI) of the applicable facility or individual depending on whether this is for a Part A facility/entity or Part B individual/performing provider. If listing a facility/entity, report the legal business name as reported to the Internal Revenue Service (IRS). 
  • You must include the name and telephone number of the person to contact regarding the pre-approval request. Providers and therapists that are currently on any type of corrective action (e.g., probe, prepayment review, probe, prepayment review, zone program integrity contractor, etc.) process are not exempt from prepayment review and should consider whether the pre-approval process is beneficial for your office. 

Regardless of whether you receive a confirmation for approval or denial of additional therapy days, once the services are rendered and a claim is submitted, First Coast will request the medical records for review prior to determining whether payment will be made.

Saturday, October 13, 2012

Open Notes Can be Transformational for Physical Therapy

I've been using video to record the patient experience in my outpatient physical therapy clinic for several years. I've never shared that video via the internet with my patient. But, the technology to do that now is simple.

Further, patient functional status, vital signs, objective tests - all these can be shared via the electronic medical record in the physical therapists' clinic.

Watch this video below to see how OpenNotes can change lives and improve health care, including physical therapy:


I posted on OpenNotes here.

Some of the ways I think OpenNotes can help physical therapists include the following:

  • Reduce overblown estimates of "Fraud and Abuse" that are due to good, smart hardworking therapists working in a stupid system.
  • Increase patient involvement and compliance with their plan of care. 
  • Improve therapist productivity that is whittled away working on archaic, frequently handwritten, narrative summaries of the patient experience.
  • Pass control and responsibility for the rehabilitative process from the therapist to the patient. 
  • Increase the role of the "coach" and the "mentor" played by the physical therapist. 
  • Reduce the administrative burden (currently 100%) borne by the therapist for the creation of the patient record. 

Do you think OpenNotes of some sort could improve physical therapy?


Please leave a comment.

Friday, October 12, 2012

The Incredible Opacity of Physical Therapy

There is no setting more opaque than physical therapy.

Not cardiology. Not orthopedics. Not family practice. Many consumers don't even know what a physical therapist does.

"Did you have study to be a physical therapist?" asked my elderly patient yesterday. I've treated him, on-and-off, for the last four years. The blow-up version of my diploma from the University of Florida (Home of the Fight'n Gators!) occupies about one-third of the wall space in a prominent place in my clinic.

"Yes," I answered gently. "I did study. I went to physical therapy school," I said.

Part of the problem is that even physical therapists don't have a conventional way of describing what we do. Oh, we have jargon. We have "medical-ese". When two physical therapists or therapist assistants talk among themselves the language can get pretty technical - just ask any patient.

"You have a capsular pattern of left shoulder mobility limitation - I don't think it's tendinitis - but instead I think you have adhesive capsulitis."

"Oh," says the patient. "What does that mean?"

The other part of the problem is that physical therapists are trained to write, to record, our findings in a narrative summary that is supposed to describe the patient experience.

The following ridiculous note is the official recommendation of a Medicare auditor in 2009:
"Quadriceps strengthening into last 20 degrees of extension with mild manual resistance and proprioceptive cueing, 30 reps to fatigue, continues to decrease current extension lag and improve quality and duration of gait."
In the new, patient-centered health care world this narrative from the therapists' perspective is clearly inadequate. Worse, it fails to communicate the value of what physical therapists actually do.

Perhaps the answer to the problem of public perception and physical therapists' value can be solved by this out-of-the-box solution: OpenNotes.

OpenNotes has been studied in a new, year-long quasi-experimental study of 13,564 patients just published in the Annals of Internal Medicine:
"Electronic portals are increasingly used to provide patients with access to their medical records and to interact with the health care system.
In this study of doctors and patients who participated in a 1-year pilot program, most patients reported that the ability to read their doctors’ office notes was beneficial and wanted the program to continue. 

Most doctors reported little or no impact on daily workload or patient anxiety or confusion."
Some of the benefits of OpenNotes include the following:
  1. improved doctor-patient relationships
  2. improved patient satisfaction
  3. no increase in workload
Let's take it one step further and increase the transparency and value of physical therapy notes. This specific recommendation for video notes comes from the authors of the Open Notes: Doctors and Patients Signing On:
"At home, patients of the future may review an unedited, automated, 2-camera shoot of a recent electronic or in-person visit to the doctor, and then discuss with family, friends, and the clinician how to modulate and finalize the note. 

Further ahead, such jointly generated and held records may evolve into a person's story over time, documenting health and illness from early days to the end of life. 

We expect that is where we are heading, but on a course filled with fits, starts, and unforeseen consequences. As the patient–doctor relationship moves forward, OpenNotes will almost certainly be on the road ahead."
Physical therapists can move forward toward this inspirational vision of the future by beginning to use video notes to record and document their patient experience.

Thursday, October 4, 2012

Current Hip Replacement Issues

Hip replacement surgery has come under fire recently, chiefly due to issues concerning metal-on-metal replacement systems. Recalls, lawsuits, complications and implant failures have made news in medical circles and even among a number of mainstream news outlets.

If your doctor has recommended replacement surgery to treat your hip trouble or you have already had an implant procedure, you're probably quite interested in finding out exactly what the controversy is all about and how all these problems are happening.

Problems and Complications
Rates of early implant failure were high among these recalled hip replacement systems, forcing many patients to undergo painful and costly surgical procedures, called revisions, to remove the faulty implants, repair the damage and install a new replacement system.
The Recalls
Over the past few years, metal-on-metal hip replacement systems made by several manufacturers have been recalled due to higher than normal rates of complications and premature implant failures.

DePuy Orthopaedics, which is a division of Johnson & Johnson, recalled its ASR Hip Resurfacing System and ASR XL Acetabular System. Two implant products made by Stryker Orthopaedics were recalled: the Rejuvenate and the ABG II modular-neck hip stems. Zimmer Holdings recalled its Durom Cup temporarily, returning it to the market with revised instructions, and Smith & Nephew recalled a component of its R3 Acetabular System.

Implant debris is the source of some of the more serious complications seen with these products, shed due to the friction between components as the patient walks. In the recalled replacement systems, design flaws and improper alignment of the components caused more wear and debris than is usual in hip implants, leading to high rates of debris-related complications and revision surgeries.

Among the most serious of these hip replacement complications is metallosis, which occurs when the soft tissues around the implant are contaminated with metallic debris particles. This can lead to severe pain and inflammation, tissue death, and bone death, often causing implant loosening and failure. In some cases, high levels of metal ions were also found to be circulating in the blood system, disbursed throughout the body. The long-term consequences of that widespread metal contamination in the body have yet to be determined. However, the U.S. Food and Drug Administration (FDA) states that metal ions in the blood can cause other symptoms or illnesses in the nervous system, thyroid gland and heart.

FDA Information and Recommendations
The FDA cautions that patients who have metal-on-metal hip replacements should watch for symptoms that include pain in the groin or leg, swelling at or near the hip joint and a limp or change in walking ability. If these symptoms emerge, patients should be thoroughly examined, and may need testing, including imaging tests, joint aspiration and blood tests to measure levels of metal ions in the blood. The agency also recommends that patients watch for general health symptoms, such as chest pain, shortness of breath, changes in vision or hearing, numbness or weakness, weight gain, fatigue and changes in urinary function.

Elizabeth Carrollton writes about defective medical devices and dangerous drugs for Drugwatch.com.

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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 .

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