Why I Couldn't Participate in the DOTPA Pilot Study

I can't use the DOTPA self-reports for care planning and goal setting in my outpatient physical therapy clinic.

The 17-page evaluation and the 16-page discharge note are not intended to be a part of your patient's clinical record. You are not expected to make clinical decisions based on the data recorded.

I can't use the AM-PAC (from which DOTPA is derived) without paying the license fee. The folks at Research Triangle International (RTI) offered to see if the AM-PAC was available, in the full, commercial version, for data collection - but, it was not.

I am not alone. Researchers associated with the RTI project have objected, on scientific grounds, that the DOTPA project...

"...developed a proposal that demonstrated a scientifically deficient and naïve review of existing instruments available for patients receiving outpatient therapies."

Specifically, the researchers charged, the DOTPA tool is less...

"...sensitive to change (than competing measures) and since payment might be based on these measures, it is essential to have the most sensitive measure for the clinicians to gain the most reimbursement when warranted."

I can't ask my therapists to perform "double entry" for several reasons:

1. My profit margins not sufficient to support the administrative burden.
2. Studies of paper-based and computerized Clinical Decision Support systems show that "double entry" is a major source of system failure.
3. My patients would object.
4. Pen-and-paper measures are a step backwards in this era of computerization, automation and electronic decision support tools.

Our Medicare Compliance plan is based on the following:

• data-driven decisions
• setting quantitative goals
• knowing when minimal change occurs to demonstrate progress
• knowing, based on quantitative progress scores, when to apply the -kx modifier for patients eligible to exceed the $1,860 PT/SLP cap

Using the DOTPA tool would not only have imposed expensive and time-consuming burden on my therapists but my physical therapy notes would have become LESS COMPLIANT for Medicare.

Who can use the DOTPA tool?

Interesting story.

I invited a friend and a peer to listen in and share notes on my phone line to the original RTI conference call on August 19th, 2010.

She was using, at that time, NO outcome measures - for her the DOTPA project was a step in the right direction.

Physical Therapist Payment Options #3

This is the third option discussed in the 2011 Proposed Medicare Physician Fee Schedule published in the Federal Register on June 25th, 2010 and open for public comment until August 24th 2010.  I discussed Option # 1 and Option #2 in previous blog posts.

You can submit your comments directly to Medicare using this link. According to the American Physical Therapy Association (APTA):

If you attach the document, please make sure to include a statement in the text box (e.g. “I am attaching comments in response to the proposed physician fee schedule rule. Thank you for your consideration.”)

Please note that this blog is independent of the APTA and my opinions or blog posts are not in any way associated with the APTA.

Option #3

Twelve new Evaluation and Intervention (E/I) codes that would capture the History, Physical Examination and Medical Riskiness of the physical therapy evaluation.

	Evaluation/Assessment Complexity
Intervention Level	Minimal	Moderate	Significant
None	E/I code #1	E/I code #2	E/I code #3
Minimal	E/I code #4	E/I code #5	E/I code #6
Moderate	E/I code #7	E/I code #8	E/I code #9
Significant	E/I code #10	E/I code #11	E/I code #12

A Significant complex evaluation with Significant interventions would rate a #12 E/I code - the highest payment. Most of the PT diagnoses would be codes #4-9. Also, only physical therapists, physicians or non-physician practioners could bill codes #1-3 and #7-12. Physical therapy assistants could also bill codes #4-6.

Physician Evaluation and Mangement codes are discussed here and using the Interactive Worksheet at First Coast Service Options (Florida Carrier/Intermediary).

Benefits Option #3 represents the closest approximation to physican Evaluation and Management codes that are valued based on...

• History
• Physical Examination
• based on the number of body systems reviewed and
• Medical Decision Making that looks at
• Number of Diagnoses
• Amount of Data reviewed (eg: lab results)
• Risks associated with medical decisions

Holding physical therapists accountable to this standard of decision making can improve our professional autonomy by increasing the demand for data collection.  Basically, the more data you collect the better your reimbursement rate.

Moving away from Fee-for-Service in this way may reward quality over quantity.  Is it possible that the very best physical therapists could see HIGHER reimbursements as they learn the new system and finally get paid better than their "average" peers?

Risks Physicians overutilize testing, mainly diagnostic imaging, in order to reduce professional liability. This reliance on expensive, modern testing drives up healthcare costs and increases the incidence of false-positives, physiologic diagnoses and inappropriate surgeries.

Fortunately, physical therapists do not share this risk. Greater data collection to reduce Medciare Audit risk SHOULD be a goal of any alternative payment system.

Bundled payments, however, are unfamiliar to most small medical providers and may provide inadequate reimbursement for the most complex cases.

Time Frame: 2 to 4 years to implement.

My Call: This is an option I would like to see discussed further - if only for the reason that it suggests that physical therapists can and do make decisions of similar comprehensiveness, complexity and riskiness as physicians.