Taking Routine Blood Pressures in the Physical Therapy Clinic

Physical therapists should be taking routine blood pressures in the physical therapy clinic.

We have evidence that physical therapists don't routinely assess blood pressure from Jette and Jewell's April 2012 study in Physical Therapy Journal.

Only 11% of 2,544 physical therapists in all settings measured and followed-up with blood pressure. Every time your patient comes in you, or a member of your staff, should take and record their blood pressure.

The Centers' for Disease Control and Prevention (CDC) reported today that over one-half of American's have hypertension defined as

"...average systolic blood pressure (SBP) greater than 140 mmHg or an average diastolic blood pressure (DBP) greater than 90 mmHg, or currently using blood pressure (BP) lowering medication."

Over one-third of Americans with hypertension were unaware of their problem and 90% of them had a usual source of care - that is, they had a doctor.

According to the CDC report: Vital Signs: Awareness and Treatment of Uncontrolled Hypertension Among Adults — United States, 2003–2010

"Nearly 90% of U.S. adults with uncontrolled hypertension have a usual source of health care and insurance, representing a missed opportunity for hypertension control. 

Improved hypertension control will require an expanded effort and an increased focus on blood pressure from health-care systems, clinicians, and individuals."

This is a major opportunity for physical therapists to assume an increased role in the care of Americans.

Physical therapists can position themselves as primary care providers by providing increased blood pressure monitoring and referral. Primary care providers, physicians and otherwise, will be an important workforce component for hospital systems participating as Accountable Care Organizations (ACO) within the Medicare Shared Savings Program.

Finally, to prevent a Medicare Audit a physical therapist can document routine blood pressure measure before, during and after exercise can show Skilled Physical Therapy.

"Skilled Physical Therapy" means that your service normally wouldn't be provided by a lesser trained provider, such as a massage therapist or athletic trainer.

Physical therapists work on medically complex patients where safety is a key concern. We know that 7% to 12% of individuals experience an adverse response to exercise. Adverse response is defined as:

"...an exercise-induced change that worsens a risk factor (such as BP) beyond measurement error and expected day-to-day variation."

Physicians probably cannot detect these individuals reliably. Physical therapists could measure blood pressure changes during and after and on multiple sessions of exercise. Adverse changes could provide the physical therapist with cues that could indicate a change in the Plan of Care or referral.

Skilled Physical Therapy Tied to Medicare Improvement Standard

Many physical therapists still believe that Medicare will not pay for therapy that does not lead to a change in functional status.

This is NOT true.

The Medicare Improvement Standard...

"...has a particularly devastating effect on patients with chronic conditions such as

• Multiple Sclerosis
• Alzheimer's disease
• ALS
• Parkinson's disease
• paralysis."

According to the Center for Medicare Advocacy:

"People with chronic conditions and long-term illnesses are often denied Medicare coverage because their medical condition will not supposedly:

• Improve on functional status scores
• They need maintenance services only
• They have plateaued
• They are chronic and stable

These reasons are referred to as the Medicare "Improvement Standard."  

Medicare is often the only insurance for this population, so, unfortunately, Medicare coverage denials can result in the loss of necessary health care.

This short podcast (7:11) from the Center for Medicare Advocacy may help you understand some of the issues these patients face in trying to get their necessary healthcare.

Unfortunately, due the the complex nature of Medicare documentation many physical therapists must waste valuable time learning how to document "skilled physical therapy" rather than actually treating patients.

I have found that patients often encounter barriers from their own physical therapists who may be uncertain or afraid to append the -KX modifier when care beyond the $1,880 is clearly necessary.

If patient progress is slow, marked by significant setbacks or difficult to measure the physical therapist may refuse to continue treating the patient.

Even though the patients' Medicare benefit allows physical therapy for these conditions.

The physical therapists' reluctance is due to fear of a Medicare Audit.

The Center for Medicare Advocacy has pressed a class action lawsuit against Kathleen Sebelius that may force Medicare to acknowledge its illegal "Improvement Standard" so that physical therapists may gain some clarification on our documentation requirements.

Please share tips on how YOU document exceptions to the $1,880 physical therapy cap.

Management and Measurement of Primary Care Physical Therapy

I'm sure the BEST primary care physicians in America are consistently measuring this important clinical variable in their older patients as a predictor of mortality and a gauge for the medical necessity for certain services, such as physical therapy.

However, I'm even more sure that MOST physical therapists are using this important clinical tool.

Physical therapist managers may even use 10' Gait Velocity to improve their clinical documentation and prevent a Medicare Audit.

This television news report shows how walking speed measurement is becoming more contemporary.

 

The August 2009 Journal of Geriatric Physical Therapy paper titled Walking Speed: The Sixth Vital Sign presents a helpful graph that I recommend every physical therapist manager include in their therapists' toolkit.

This 2001 Journal of the American Medical Association (JAMA) paper describes how the best academic physicians are beginning to recognize the value in documenting and treating slowed gait in elderly people as a primary source of disability.

I'd like to see the 10' Gait Velocity (Walking Speed) tool used as a screening device in a primary care setting that might allow physical therapists to do the following:

• assess populations of patients eligible for treatment
• score their risk for a future fall or disabling condition
• treat them proactively or refer them, as necessary
• and lower future health care costs.

Who else thinks this is a good idea?

What's So Bad about Physical Therapy Documentation?

I subscribe to a number of web feeds - some good, some bad.

I recieved the following e-mail the other day. It is a Medicare Compliance advice column that purports to help physical therapists improve their documentation "quality".

"To improve the efficiency of your note writing, eliminate words or phrases that don't lend to the quality of the note such as, "Patient reports they really enjoy coming to therapy".   

Instead write, "Patient reports now being able to bend their knee to tie their shoe."  

The first statement, who cares? The second statement is a subjective report of objective functional improvement."

What's so bad about this advice?

 

Nothing. You might get an A+ from your physical therapy school professor.

But, does this note add value to your physical therapy encounter?

• Does your narrative note improve the patients' functional outcome?
• Does it improve patient satisfaction?
• Does your choice of words lower healthcare costs, going forward?

I'm not trying to pick on the author of this note. His advice might prevent or ameliorate a Medicare Audit. I might have given this same advice earlier in my career.

That's the problem.

Physical therapists are some of the highly educated, patient-focused and cost-effective healthcare providers in the United States today. There are about 177,000 of us and we can make SO MUCH of a difference in peoples lives.

But, instead we're being told to write this garbage.

Physical therapists must write these notes, we are told, to protect the clinic from a Medicare Audit.

Yet, the future of healthcare is moving towards a technologically-driven workforce that anticipates adverse patient events rather than responding to them. Adverse events such as...

• Community Acquired Pneumonia (a leading cause of hospital re-admissions)
• Prevention of Deep Vein Thrombosis (DVT) in our post-surgical physical therapy patients. Note, the incidence of DVT in the USA is rising, not falling.
• Disability in Americans is also rising. Our patients can't walk, climb stairs or button a shirt as well as their parents could.

Physical therapists should be focused on how to PREVENT these future adverse events and episodes of disablement and institutional care.

Physical therapists should NOT be writing narrative notes.

What Will Future Physical Therapy Documentation Look Like?

We can get a clue from the Health Information Management Systems Society (HiMSS) criteria for Electronic Medical Records implementation. Their highest level, achieved by several medical centers in America, Canada and Europe, is called the Health Level Stage 7 (HL7).

These criteria included the following:

• No paper charts
• All images are contained in a Picture Archiving and Communications System (PACS) within the EHR in the hospital.
• All data is entered as a discrete element called “structured data”.
• All structured data is contained in a Clinical Data Warehouse (CDW) where sophisticated algorithms look for patterns, such as disease outbreaks or heightened risk profiles in individuals.
• The CDW also puts out regular outcome reports at the level of the hospital, the clinic and the clinician.
• All services (eg: inpatient, outpatient, urgent care, PT, etc.) can produce standardized Summary Data for improved transfers and discharges.
• All computer systems are interoperable (eg: EMR, EHR, PHR)

Note that there is no place for physical therapists' free text narrative drivel in the HL7 paradigm.

I wonder where all the Medicare Auditors will find work once every hospital system and clinic is at the HL7 level in a few more years? :)

New Book on Clinical Decision Support in Physical Therapy

The new book is finally done!

Bulletproof Expert Systems began in 2006 when myself and six other physical therapists and physical therapist assistants attempted to standardize our clinical documentation.

From those early beginnings, in a series of workbooks, clinical manuals and in-services and, finally, seminars - this book was born.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting shows how physical therapist mangers and clinic owners can use existing clinical tools (such as paper-based or electronic outcome measures) to do the following:

1. standardize documentation
2. improve decision making
3. improve productivity
4. create a brief, transparent clinical record that will defy a Medicare audit
5. improve your clinical outcomes

The publisher's web page went live January 7th, 2012 where I am providing the book at a substantial (~40%) discount from the on-line retailers.

You can buy the discounted book at the publisher's web site.

Finally, I need help selecting the final banner design - if you could just vote for one of the three finalists below I will be all set.

Thank you for your patience and the encouragement I have recieved from all my readers!

This have been an amazing educational and professional journey and its one I could not have made without you!


Thank you!

Physical Therapist´s Payment Option # 1

Three new poposed payment options related to the Medicare Physician Fee Schedule were published in the June 25th Federal Register and are available for public comment until August 24th.

The immediate concern is the proposed Multiple Procedure Payment Reduction (MPPR) policy but there are additional concerns that deserve physical therapists´ attention. I´d like to review the alternative payment options:

• Option #1
• Option #2 and
• Option #3

...and make recommendations for or against. As always, your comments are welcome on this blog. Also, please use the link provided to make public comments on the proposed MPPR policy directly to your government.

Note that CMS is not specifically recommending these alternative payment policies, at this time.

Option #1: New Severity and Function codes

The Centers for Medicare Services (CMS) would require physical therapists to replace the -KX modifier with new HCPCS Level 2 codes at Evaluation and Progress Note intervals (30 days or 10 visits, whichever is less).

PT Test or Measure	Function Codes	Code Description
Impaired Step Down Test	GxxxU	Body Function/Body Structure impairment - current
Impaired Step Down Test	GxxxV	Body Function/Body Structure impairment - goal
Slow Stair Measure Test (9 steps)	GxxxW	Activity Limitation/Participation Restriction - current
Slow Stair Measure Test (9 steps)	GxxxX	Activity Limitation/Participation Restriction - goal
3 steps into home	GxxxY	Environmental Barrier - current
3 steps into home	GxxxZ	Environmental Barrier - goal

note: I have added the PT Tests and Measures to show how these codes might be supported by evidence-based data in the patient chart.

Two severity modifiers have been proposed. This first chart shows modifiers based on the ICF:

Severity Modifier	Descriptor
0-4%	None
5-24%	Mild
25-49%	Moderate
50-95%	Severe
96-100%	Complete

This second chart shows modifiers for impairments, limitations and/or barriers as simple percentages:

Severity Modifier
0%
1 to 19%
20 to 39%
40 to 59%
60 to79%
80 to 99%
100%

Benefit: The policymakers are using International Classification of Function (ICF) descriptors to link physical impairments to function in a way that can be analyzed through claims reporting.

This option explicitly defines patient progress by comparing current and expected (goal) function.

CMS believes this option will lead to a decreased reporting burden because the -KX modifier would not be need on each claim line for patients over or near the PT caps.  Instead, only the new severity and function codes would be reported at (re)evaluation and Progress Note intervals.

These codes would also provide more information for medical review - at this time medical review (Medicare Audit) is a highly variable process that imposes provider liability based on largely pen-and-paper scribbled, narrative notes.

Risk: Physical Therapists in Private Practice (PTPPS), hospitals outpatient departments (Part B) and other settings may not routinely assess firsthand patient environmental barriers, especially those in the patient´s home.

Also, the link between physical impairment (body structure and function) and functional limitations (Activity and Participation Limitations) is tenuous and poorly described in the PT literature.

If such a link does exist it is probably NOT the linear, staight line conceptualized by Nagi in 1965 or the ICFDH in 1981.


This new coding scheme seems to hold physical therapists accountable for a conceptualized framework that is popular to academics and policymakers but is often absent from clinical realities.

Time Frame: Six months to two years.

My Call: I like this option because it gives physical therapists the chance (for the first time) to send claims-level data to CMS about the quality of physical therapy. 

This option may protect physical therapists from the Medicare Auditors´ concept of "skilled physical therapy" as a reason to deny claims.

Physical therapists prepare for Medicare RACs

It's a shame that our Federal government now sees health care providers as a revenue source - (tongue-planted-firmly-in-cheek) - this may be our contribution to balancing the federal budget!

Holland and Knight attorneys have penned this helpful 25-point list for providers to consider when you consider Recovery Audit Contractors (RACs). Note that most of the audit protection measures are aimed at inpatient hospitals - that's because most of the money is in inpatient hospitals not in small, private practice physical therapy clinics.

Nevertheless, PTs may want to familiarize themselves with audit risk in general and with small practice compliance specifically. Get the small practice compliance template here.

This blog has previously commented on our experience with the RAC demonstration project in Florida (2005-2008) and the amount of the adverse impact on PTPP, on average.

We have included a chart that describes the average repayment amount from physicians (PTs are lumped in with physicians).

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80/year	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

Note, I have revealed my own clinics' individual repayment experience.

Nationally, over the three-year demonstration period private practice physicians and physical therapists groups have repaid only $19 million from a total over- and under-payment determination of over $1 billion dollars.

Consider the circumstances in the demonstration project - if an overpayment determination reached the third level of the appeals process (Administrative Law Judge) then the RAC was not paid for the overpayment.

Now, in the permanent RAC (2009 going forward), if an overpayment is appealed at any level (1st, 2nd or 3rd) then the RAC will not be paid - this is a HUGE incentive for the RAC to avoid cases which seem likely to appeal, at any level.

Many hospitals have pledged to appeal every overpayment determination based on this rationale. Holland and Knight attorney/blogger Greg Piche' advises against 'knee jerk' audit appeals - only appeal those findings that seem unwarranted and excessive.

Small PT practices may have limited resources (time and money) to automatically appeal every time but with "skin in the game" an owner is personally incentivized to appeal large overpayments based on "medical necessity" (the most prevalent audit finding).

Medically unneccesary physical therapy speaks to the "home court advantage" of small private practices - how well do you know your patient and how well do you document your evaluation findings?

Most practice owners do a very good job with the face-to-face interaction. It should be a simple matter to go one step further to use a standard documentation format to show medical necessity.

The OPTIMAL is one such format to create baseline self-report data that shows medical necessity (need) for physical therapy.

Other baseline formats include the following:

• performance measures (like TUG test, Single Leg Stance time, etc.)
• impairment measures (like Straight Leg Raise, hip internal/external rotation ROM, etc.)
• treatment-based classification measures (like traction, manipulation, stabilization, etc.

Standard baseline formats that are evidence-based are recognizable to Medicare RAC 'audit police' - especially those that are also physical therapists! If, upon reviewing your charts the auditor finds standard tests and measures they are likely to recommend 'moving on' to the next case - your case will be too likely to win on appeal.

RAC audits are an unlikely but persistent threat for small practice physical therapists. The federal governement's current budget difficulties have only increased the need for 'self-funding' programs like the RACs.

Therefore, RACs seem unlikely to go away in the near term.

I saw Rosa today in PT...

I treated a very sweet lady named Rosa today. Rosa weighed in at over 225 pounds at a little over five feet tall. Rosa presented in the clinic with her rolling walker and her daughter in tow.

Rosa had a physician employed by an insurance company who did everything she could to keep from sending patients to physical therapy because she was financially penalized for referrals to costly ‘ancillary services’.

Rosa had seen pain management, rheumatologists, internists and orthopedic surgeons for persistent unilateral rib pain. Rosa had fallen twice in the period she had been seeking help. She had refused injections and had asked for physical therapy on more than one occasion.

Rosa’s daughter insisted that her mother needed electrical stimulation. The daughter’s chiropractor used electric stimulation twice a month on the daughter's neck ‘for over a year’ to the daughter's apparent satisfaction.



Rosa could barely stand up in from the chair but she ended up that day with me doing many varieties of performance testing:

• Timed Up and Go Test
• Functional Reach Test
• Balance and Reach Test
• Timed Tandem Standing
• Timed Single Leg Standing
• a few impairment measures.

To Rosa's surprise, movement felt better. She could feel the spasms in her rib easing as I had her reach out over her base of support. I could see the daughter was visibly impressed at the tasks I was getting her mother to do.

Rosa left that day feeling better and didn’t get sore the next day. She declined the electric stimulation on the first visit because of time.

Patients like Rosa can often benefit with just one type of treatment intervention. In Rosa' case, reaching offered the greatest immediate benefit.

Rosa's Story is an Example

Rosa's story is an example of the clinical benefit offered by standardized testing. Also, each of the measures mentioned above produced a valid and reliable measurement. Some of the measurements have known change scores that reflect true change to assess progress. Finally, some of the measures are predictive for falls. Improving these measures should decrease the patients' risk of future falls.

Mock Audit

Our clinic started using predictive performance measures after we had a mock Medicare audit performed on five of our "Bulletproof" charts. The audit pointed out 'weaknesses' in our Medicare compliance program, namely, the insufficient use of performance measures in high risk populations.

Your clinic Medicare compliance program can benefit, as mine did, from following guidelines promoted by the Office of the Inspector General, namely:

• Conducting internal monitoring and auditing;
  
• Implementing compliance and practice standards;
  
• Designating a compliance officer or contact;
  
• Conducting appropriate training and education;
  
• Responding appropriately to detected offenses and developing corrective action;
  
• Developing open lines of communication; and
  
• Enforcing disciplinary standards through well-publicized guidelines
  

The five charts I sent out for audit have been very helpful to me in upgrading, updating and further "Bulletproofing" my private practice physical therapy Medicare compliance program.

To learn more, sign up for the free Bulletproof PT decision-making tutorial below.

Justify your Physical Therapy

How do you 'justify' your physical therapy?

How do you 'prove' that your patient needs physical therapy and is benefiting from your care.

Many physical therapists think that the patients verbal statements "I feel better!" placed in the written chart is sufficient to justify services to Medicare patients.

Many therapists use a simple outcome measure to show progress and demonstrate need.

Is one simple outcomes measure and patient "subjective" statements sufficient to exceed the $1,840 therapy cap?

Probably not.

Centers for Medicare and Medicaid (CMS) Transmittal 88 states the following:

"It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed."(p.23)

A narrative is a statement that says "Here is why I am putting the '-KX' modifier on my charges - here is why I think my patient qualifies for Medicare Part B benefits over the therapy cap."

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 their 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. (p.24)"

If the record justifies...

That is a big IF...

This Justification Statement is the one my facility uses to PROVE our patient deserves their rightful Medicare benefits.

It also protects me from unfair fines or repayments if I get audited.

Disclaimer: I am a physical therapist in private practice - not a Medicare auditor. You should make your own decision as to the veracity of my statements and the extent to which my recommendations fit with your own compliance program.
I do not give individual compliance advice.

Note in the Justification Statement how various levels of clinical evidence support and reinforce each other:

• outcomes measures
• performance measures
• impairment measures
• written patient statements

"Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus." (p.26)

Your patients deserve the therapy they need.

Some facilities automatically discontinue physical therapy when allowed charges hit $1,840 - regardless of whether patient goals are met.

Is that fair?

Is Medicare compliance related to clinical competence?

Bulletproof Decision Making started out as my own professional exploration of Medicare chart compliance for my private practice physical therapy clinic.

(note: you can sign up for Bulletproof at the bottom of this page)

I wanted to make a better compliance plan for my Medicare charts and notes.

My starting assumption was that good clinical documentation is completely related to competent clinical decision-making.

It is not.

Good clinical documentation today (2009) is all about dotting your 'i' s and crossing your 't' s.

What I learned

In early 2009, I paid a Medicare auditor $1,000 to come in and examine my charts and comment upon my compliance program. As you might expect, the auditor was able to find many 'deficiencies' in my charts.

I realized then that, to be helpful to other private practice therapists, Bulletproof needed to be about physical therapists' decisions driving treatment, documentation and compliance.

Why do physical therapists' decisions matter to Medicare?

Within a few short years, physical therapists may track their patient outcomes using remote data-gathering technology such as e-mail, web-based forms and CAT testing.

Patients could enter their own data.

This should reduce the 'information asymmetry' that has led some insurers to refer to physical therapy as a 'black hole' into which money disappears.

Currently, 52% of physical therapists do not use outcome measures which means that payers have no information showing if their beneficiaries got better, or not.

Electronic, standardized outcome measures will provide information on patient functional progress as well as initial and ongoing medical necessity for physical therapy.

Who are the Doctors?

Expansion of physical therapists' ability to serve as front-line health care providers means that the complexity of physical therapists decisions will determine the extent and intensity to which those services can be billed.

Physical therapists will bill like physicians.

Currently, physicians use Evaluation and Management codes (E/M) , that one day I hope physical therapists will use.

Payment to physicians is based on the following:

• an extended patient history
  
• detailed, multi-systems exam
  
• number of diagnoses
  
• complexity of decision-making
  

How do compliance and competence relate to each other?

Bulletproof is a resource that prepares physical therapists for the day when our decisions drive practice: when the frequency, intensity and need for physical therapy are derived from our physical therapy diagnosis.

The duration of physical therapy will be derived from the physical therapy prognosis.

I eagerly await the day when a Medicare audit of my charts is based, not on my handwriting or my chart templates, but on my decisions and on my clinical competence.

Medicare RACs attack

As noted across the blogosphere the Medicare Recovery Audit Contractors are aiming their guns at health care providers after a 4-month hiatus.

Their primary target is inpatient hospitals.

That's where the money is.

Witch Hunt?

The federal government sees health care providers as a revenue source.

RACs bid for the right to audit and collect overpayments from providers. The RACs then keep a portion of those overpayments.

Some say the rewards to the RACs could lead to over-aggressive collection efforts.

Do you think RACS are unfairly incentivized to target and collect overpayments?

Do you think physical therapists in private practice need to worry?

Physical Therapists and Physicians have something in common

Physical therapists and anesthesiologists have something in common.

Both professions have difficulty showing need for their services.

1. Exercise by physical therapists.
   
   
2. Facet joint injections by anesthesiologists and other physicians.

This report by the Office of the Inspector Generals' (OIG) indicates physicians have difficulty showing medical necessity for spinal facet joint injections.

Eight percent of the claims were paid despite no evidence (x-ray fluoroscopy) that the services were medically necessary. The overall paid claims error rate for facet joint injections was 63%.

Physicians use fluoroscopic imaging to demonstrate pathology necessary for medical diagnosis and treatment by facet joint injection.

However, the...

"...lack of consensus in the medical community about appropriate frequency of injections is a barrier to creating frequency limits in Local Coverage Determinations."

Thirteen of the 15 Medicare Carriers have Local Coverage Determinations that set forth medical necessity requirements for facet joint injections.

"Carriers are also responsible for implementing program safeguards to reduce payment errors. To accomplish this, carriers create local coverage determinations (LCD), issue instructional articles implement claims processing edits. Carriers also analyze data, conduct provider education, and conduct medical reviews."

An uncertain environment

Physical therapy medical necessity is even more ambiguous - for instance, there are no National or Local Coverage Determinations (LCD) that determine the criteria for physical therapy services like the following"

• Therapeutic Exercise (97110)
  
• Manual Therapy (97140)
  
• Neuromuscular Reeducation (97112)

Currently, the standard for physical therapy medical necessity is the 'expert opinion' of a Medicare auditor (who may or may not be a physical therapist).

The 'expert' reviews your written notes to see if the exercise codes you billed Medicare are necessary.

"It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed." (Transmittal 88)

Can't physical therapy reporting get more transparent, less hazardous or both?

Why, when our focus is patient treatment, should we be forced to spend valuable patient time on lengthy notes and charts?

Own Your Own PT Clinic

Own your own PT clinic.

Owning your clinic is the dream of many smart, young physical therapists.

Treat how you feel your patients should be treated.

Do good work.

Get paid.

That's how I got started.

But I started with partners and I bought them out.

Out with the old and in with the new.

That's what I thought, at the time.

It was all mine.

*****

Then I looked around.

And there it was...

Something old, still there.

Sitting on the shelf, dusty.

An old three-ring binder.

Pages yellow with age.

When I opened it, I sneezed.

Dust flew off of the page, around my eyes.

It was the old clinic Medicare compliance manual.

Never opened.

Never updated.

Inside were ten, yellow typewritten pages.

Typewritten... On a typewriter.

The Manual

The pages contained, believe it or not, instructions on how to assemble hot packs and instructions to aides on how to treat patients.

There was actually a copy of a referral pad with a physicians' signature line that stated the following:

"These treatments are Medically Necessary for the patient to receive physical therapy services."

There was a diagram of the floor plan with the fire escapes marked in faded red marker.

The manual had one page that told what to do in the event of a hurricane.

It had another page that listed vacation days.

Wow.

The Date

I found a date.

1988.

That's when I started to panic, a little.

My Action Plan

I decided to get busy building a plan.

I took a seminar by an expert Medicare consultant.

According to the expert, my notes were so far out of compliance there should have been a red, neon label that said "Audit Me!" attached to every charge I sent to Medicare.

That's when I started to panic, a lot.

I decided to learn everything I could about outpatient physical therapy Medicare compliance.

I took more seminars, bought books, read newsletters, called my practice association and, in general, specialized in outpatient physical therapy Medicare compliance.

I excitedly went to my staff, 7 PTs and PTAs.

I told them everything I had learned.

You know what happened?

Big yawn.

Some PTs and PTAs fell asleep during my presentation.

Some were more polite about their disinterest.

Bottom line, the notes and charts didn't get much better.

Why?

It didn't matter.

I hadn't shown my staff why and how Medicare compliance made better physical therapy.

I hadn't shown my staff how they could help their patients more with better notes.

My PTs and PTAs just wanted to treat patients.

They couldn't see why and how notes could help them do that.

I had to do better.

I went back to the drawing board - I made Bulletproof Physical Therapy Notes and Charts.

Bulletproof is uses three, public-domain tools to show physical therapists' decisions - the core of your skill set.

Bulletproof uses templates to show progress and need for PT.

Bulletproof also describes dozens more tips, techniques and strategies for physical therapist mangers and educators to train PTs and PTAs to get Bulletproof Notes and Charts.

There is no three-ring binder to keep from getting dusty.

So far, the results are very encouraging.

My staff and my patients are happier than ever.

We are confident now when we append the -kx modifier, start a second month of therapy or just write a daily note.

Now, I'm not scared anymore.

Finally, I'm living the dream.

Does Physical Therapy Cost Too Much?

Some physical therapists over-treat their patients.

The most expensive Medicare physical therapy patient in America received $114,799 in services in 2004.

By 2006, the most expensive Medicare physical therapy patient in America only cost $37,543.

The difference in 2006 vs. 2004 was the implementation of the 'per beneficiary caps' on outpatient rehabilitative services.

The chart header below reads 'Annual Per Beneficiary Payment Threshold Change Per Percentile' and it shows the amount of physical therapy received, in dollars, broken down by percentile.
The next chart is the same data set, with the 100th percentile removed.

Notice how the chart scale shifts and the differences between 2006 vs. 2004 are made apparent.
These two charts are taken from data provided by the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2)

The data for these charts is available in the OTAPS 2 report as Table 3.

I extracted and re-formatted the data as two separate charts to illustrate the impact of the 100th percentile cost outliers.

If these charts are too hard to read I have put them as PDF files at www.BulletproofPT.com.

Falling Costs

Note how costs for physical therapy have fallen across the board.

The exceptions to falling costs are those patients whose costs are below the 50th percentile (median).

Their costs are rising.

At the 50% percentile costs increased at about the same rate of growth as the overall Medicare population (3.5%).

At the 25% percentile costs increased at double the rate of growth of the overall Medicare population.

Why?

Who cares?

At $227 per beneficiary per year Medicare can afford lots and and lots of physical therapy for these people.

At $37,543 per beneficiary per year Medicare can't afford much physical therapy.

The problem is this:

How can Medicare get physical therapy to those patients who need it most while preventing egregious cost outliers like in the first chart?

What to do?

Current legislation has the caps (and their exceptions process) in place until December 31st, 2009.

An alternative payment system is expected to replace the Medicare therapy cap within the next five years.

A pilot study will get underway in May 2009.

Current patients are facing hardships when their $1,810 physical therapy dollar limit is met.

Many physical therapists are uncomfortable appending the -kx modifier if they believe it raises the risk of a Medicare audit (it does).

Do the right thing

If your patient needs therapy and you can show they get better in a timely manner, do it.

If you are unsure or scared about how to document your findings then check out some of the free resources at www.BulletproofPT.com, your source for outpatient Medicare documentation and compliance knowledge.

Is Ultrasound Medically Necessary for Physical Therapy?

Do you use ultrasound on your patients?

Why?

How often or how much?

When do you stop ultrasound treatments?

What are the bases for your decisions?

Do you go with the flow?

Many physical therapists choose to use ultrasound for their patients.

Patients often demand ultrasound and physicians often request ultrasound.

Ultrasound is often criticized for its poor evidence base despite widespread anecdotal reports of it's benefit.

Show your work

Here'e the easy way to demonstrate medical necessity (need) for ultrasound.

Create a simple checklist or chart template that you or your staff could fill out every time you or they select ultrasound.

Copy the template or checklist and make it part of the initial evaluation.

Have extra copies ready for those patients who request ultrasound mid-way through their treatment.

Use the checklist to describe the findings that indicate ultrasound is necessary.

Findings: Inflammation

For example, pulsed ultrasound may be used as an anti-inflammatory modality.

This chart checklist, filled out at the initial evaluation, may support the medical necessity (need) for ultrasound when used as an anti-inflammatory modality.

You may also create a template to check off the findings that support ultrasound's thermal effects for scar tissue, etc.

(YES/NO)	CONDITION	Dimensions
	Swelling
	Redness
	Tenderness
	Palpable heat
	Loss of Function

One or more of these conditions present, with the dimensions noted, could provide a basis for ultrasound.

Properly filled out initially, and at subsequent intervals for Progress Notes, this chart checklist is a decision-making tool that can help the therapist understand when certain interventions are, and are not, indicated.

As a physical therapy clinical manager it is your responsibility to provide these tools to your clinical staff to ensure a Medicare compliant chart.

When it is so easy to do - why not?

Good for the patient, the therapist and the Medicare auditor

A Medicare auditor could look at this checklist to clearly and quickly see why the physical therapist had charged for sessions of ultrasound in the physical therapy plan of care.

Some therapists have used this pen-and paper tool to explain to their patients when ultrasound, a modality with a strong placebo effect, may no longer be indicated.

Bottom line, simple tools that demonstrate your skilled physical therapy decisions and show the need for your valuable treatments are essential in today's clinical environment.

For more free tools, templates and tips on physical therapy Medicare compliance go to www.BulletproofPT.com . 

Did error rates decline for physical therapists, too?

Modern Healthcare.com posted the news that the Medicare error rate declined in 2008 for fee-for-service providers.

"Improper payments to fee-for-service Medicare amounted to $10.4 billion in fiscal 2008, decreasing to a rate of 3.6% from 3.9% in 2007, the CMS reported."

FierceHealthcare.com reported that the lower error rate was due to the Medicare Recovery Audit Contractors (RAC).

You can read about the RAC impact on physical therapists here, here, and here.

AIS Health.com reports that the RACs will be delayed a few months (probably February 2009) while some of the government contractors work through a grievance process that is related to selection of RACs, not to health care providers.

As I've previously posted there is evidence to indicate that RACs preferentially targeted large, inpatient hospitals in the 'temporary' 3-year phase.

More restrictive audit rules for the permanent RACs increase the chance that the permanent RACs will continue to target large, institutional providers and leave small ones (eg: physical therapists) alone.

Older physical therapy patients are worried

Every day I answer questions from older Americans about their physical therapy.

"Will I run out of Medicare physical therapy benefits?"

"What will happen to me - will I have to go into a nursing home?"

Medicare provides physical therapy treatment up to $1,810 in billed charges for the purpose of preventing a loss of independance in older Americans.

Americans living at home, cared for by their loved ones, consume fewer healthcare dollars than Americans living in institutions.

Medicare pays for much of the institutional care in the United States.

Sarah

Today, I treated Sarah, an 86-year old lady with arthritis.  

Sarah is legally blind and cannot walk far because of pain in her back and legs due to a condition called spinal stenosis.

Sarah's husband died a few years ago and now she is alone. 

Sarah can clean her home and care for herself with minor accomodations - she rides the handy bus to church, groceries and physical therapy.  

She doesn't go out much but she lives in a trailer park where neighbors are close by.

But, Sarah is not far from needing more help.

She has been in physical therapy for her spinal stenosis for a month now and we have gotten her back to walking and single-stair climbing (we live in Florida). 

Sarah is much more comfortablenow moving around and doing light lifting.

Friday, November 7th is Sarah's projected discharge date and she is worried that physical therapy will not continue.

She is afraid that she will decline without therapy and require more help to live alone.

Soon, she believes, she will need to move out of her trailer and into a nursing home.

Sarah believes physical therapy can help prevent this decline.

So do I.

Medicare depends on me to prevent Sarah from losing her independance and going to live in a nursing home.  But, for that, I have to make decisions that expose me to the threat of a Medicare audit if it is determined that I gave Sarah 'too much' physical therapy.

What do I do?

I must show that I can help Sarah, that Sarah needs my help and that only a physical therapist, such as I, could help Sarah.

For that I need help.  I need two tools.  Both are free tools.

The first tool is the OPTIMAL.

I use the OPTIMAL to show that Sarah needs physical therapy.

The OPTIMAL also shows that Sarah can now walk further and move around better than she did one month ago.  It shows she makes progress in physcal therapy.

But, I also need one more tool.  I need to append a '-kx modifier' to my physical therapy charges that I send to Medicare.  

I want to show any Medicare auditor that my decision to append that modifier is based on results, not just a one-time event or measurement.

So, I graph my OPTIMAL scores.

Here is the graph template.

What happens to Sarah?

Friday I take my follow-up measurements.  

Sarah's need and progress is evident.

My skill and decisions are well-documented with the graph template.

This time, I think she will qualify for the extra month of physical therapy.

Medicare Fraud Strike Force Indicts Eight in Miami

So far this and other Medicare actions in the South Florida area do not appear to have involved physical therapists.

The Medicare Fraud Strike Force arrested eight individuals in October 2008, including two doctors, charging them with conspiracy and fraud in a scheme to bill Medicare for HIV infusion treatments that were never performed.

Similar schemes involving compounding pharmacies in 2007 cost the Medicare program $20 million dollars.

In May 2007 a Miami medical billing company was convicted of fraudulently collecting $56 million from Medicare.

Medicare payments to home health agencies in Miami have increased 1300% since 2003.

Medicare is...

"focusing on home health agencies that send nurses to give homebound diabetics insulin injections. Some patients are neither homebound nor unable to give themselves the injections...Some don't even have diabetes."

So, how does this affect physical therapists?

All health care providers are suspect when these kinds of abuses occur.

Medicare must enact tougher controls to manage the system.

Better control of 'outlier' payments is first on Medicare's list.

From the October 10, 2008 USA Today -

"Randall Culp, an FBI agent who oversees a team that investigates Medicare fraud, says Medicare should move faster to revoke Medicare status for questionable home health agencies and crack down on outlier payment abuses."

If you are a legitimate outlier, for instance a manual physical therapist who charges a lot of Manual Therapy (CPT 97140) you need to make sure that your notes support your billed charges.

You need to show...

• Medical necessity for physical therapy (measurable, treatable findings)
• Expected improvement in a reasonable time frame (progress)
• Skilled physical therapy (decisions)

A legitimate outlier would have a patient population that requires above-average amounts of a particular intervention, for instance chronic low back pain.

Documented pain diagrams or patient-reported functional scales, such as the OPTIMAL can help demonstrate medical necessity for physical therapy for this patient population.

Validated outcomes measure such as OPTIMAL or AM-PAC can show progress.

Skilled therapy is demonstrated by your decisions.

Get training for improved physical therapy decision making at BulletproofPT.com.

Physical Therapists in Florida included in the RAC Rollout

Physical therapists in Florida are in the first round of states receiving provider education beginning October 1, 2008 according to an article in the September 11 AHA News.

The Medicare RAC Program is designed to augment exiting Medicare audit capacity and, in the words of former CMS Administrator Mark McClellan, M.D., Ph.D...

“There are two parts to making certain that Medicare dollars go to their intended purposes,” said CMS Administrator Mark McClellan, M.D., Ph.D. “First, we need clear and straightforward rules to assure that fair payments are made for services to Medicare beneficiaries and second we need effective mechanisms in place to detect and respond to inappropriate billing. In conjunction with new steps to ensure Medicare’s billing rules are clear, this demonstration will let us test a new approach to ensure that payments made to providers are accurate.”

This RAC expansion map shows the states affected on October 11.

My experience in Medicare Part B outpatient physical therapy is that the RAC audits affected PT's in Florida very little..

We had less than $100 in post-pay audits in the four-year scope of the three-year demonstration project.

Overall, Physician Groups had about $19 million seized as part of the RAC demonstration project.

Most of the money came from inpatient hospitals.

Get the full RAC demonstration report here.

Physical therapists and doctors: Get ready to hand over more documentation

Much in the news lately is the Office of the Inspector General Investigation of the Comprehensive Error Rate Testing Program.

As I blogged on Sunday, August 24, 2008 you-know-what will run downhill on this one.

Here is the OIG report for your reading.

In summary the report states the following:

"We recommend that CMS:

• require the CERT contractor to review all available supplier documentation;
• establish a written policy to address the appropriate use of clinical inference;
• require the CERT contractor to review all medical records (including, but not limited to, physicians’ records) necessary to determine compliance with applicable requirements on medical necessity;
• document oral guidance that conflicts with written policies, such as guidance on the need for proof-of-delivery documentation in making medical review determinations;
• instruct its Medicare contractors to provide additional training to physicians that focuses on improving their medical record documentation to support ordered DME items; and
• require the CERT contractor to contact the beneficiaries named on high-risk claims, such as claims for power mobility devices, to help determine whether the beneficiaries received these items and the items were medically necessary."

I've highlighted in red the requirement that I believe will lead to tougher audit standards on physical therapists and physicians - already overburdened with declining reimbursements and rising costs.