Physical therapists: Put your diagnosis in your goal

This extra step in your clinical thought process can dramatically improve your notes and charts for your Medicare compliance program.

The simple act of linking the measured impairment to the patients' activity limitation is one of the essential skilled components of physical therapist practice.

For example:

“Improve sidelying hip external rotation from 15cm to 25cm in order to improve OPTIMAL Balance from 4/5 to 2/5.”

Your clinical rationale is explicit in the goal – without the need for additional statements clarifying the link between measured impairments (hip external rotation) and patient activity limitations (balance).

Your physical therapy diagnosis may change from body part to body part and from activity to activity.

For example, the same patient may have the following goal:

“Improve AROM ankle dorsiflexion from 0 degrees to 10 degrees in order to improve OPTIMAL Stairclimbing from 4/5 to 2/5.”

Diagnosis differences

The interesting thing is that our diagnosis is not predicated on any medical model.

In the examples above, the written reason for patient referral was the following:

‘lumbar strain’ – ICD-9 code 722.93 (Other and unspecified disc disorder, lumbar region).

The physical therapist independently identified the two above mentioned areas above that needed attention that could not be consistently predicted by the medical diagnosis.

The ICF model, on the other hand, more accurately identifies the work and the decisions made by the physical therapist.

A physical therapist might diagnose, using these ICF codes, the activity limitations and impairments in body structure and function.

ICF Domain	ICF descriptor	ICF code
Activity	Walking on different surfaces	d4502
Body structure	Muscles of ankle and foot	s75022
Body function	Mobility of a single joint	b7100

Using a disablement model as the decision-making framework and making the commitment to always diagnose every patient the physical therapist is freed from the subservient, technical position in the medical model.

The physical therapist is put in the position of making decisions that are in the best interests of the patient, based on the finding from the physical therapy evaluation.

No other professionals are examining patients at this level:

• not physicians
  
• not chiropractors
  
• not massage therapists
  
• not athletic trainers.
  

Decision-making and the physical therapists’ diagnosis are the sustainable competitive advantage of physical therapy over all of these other professions in the care and rehabilitation of our patients.

Put your diagnosis in your goals to improve your written work.

Physical Therapy Diagnosis: Label or Process?

The new International Classification of Functioning, Disability and Health (ICF) speaks to the central decision physical therapists make in clinical practice:

What is wrong with the patient?

The ICF model seems to avoid the use of descriptors, or labels, that can be used to describe conditions related to human movement.

Fine with me.

The ICF Browser has descriptors of the following:

• Body Functions
• Body Structures
• Activity and Participation
• Environmental Factors

...that affect human movement and function.

Using ICF, I could make a diagnosis on a patient with neck pain that would look something like this...

"Patient has difficulty Bending, Sitting and Pushing (all measured by OPTIMAL scale) due to the following:

1. Stiff upper cervical sidebending (C0-C2).


2. Weak deep cervical flexors (DCF) muscles (measured by flexor muscle endurance test).


3. Decreased cervical rotation ROM, bilateral.
   

...to be treated with the following...

1. Therapeutic Exercise (97110) for endurance of DCF muscles.
2. Manual therapy (97140) for ROM, PROM, massage.
3. Neuromuscular Reeducation (97112) to distinguish cervical sidebending from cervical rotation.
4. Therapeutic Activities (97530) for Pushing with a stabilized cervical spine."

The descriptors used in ICF all have to do with measured findings.

The descriptors for the above diagnosis are the following:

Body Function:

• Mobility of several joints (b7101)
• Endurance of isolated muscles (b7400)

Body Structure

• Ligaments and Fasciae of the Head and Neck (s7105)

Activities

• Bending (d4105)
• Sitting (d4103)
• Pushing (d4451)

Without inventing a nomenclature or supposing the existence of any mechanism or model the physical therapist is able to accurately identify the structure at fault, the proposed treatment and the effect on the patient.

I make this diagnosis about 5-6 times per week.

Most of my patients (60%) are Medicare beneficiaries with typical, routine presentations that require a typical, routine evaluation.

I don't try to 're-invent the wheel' for each new patient I see.

I do take measurements for each descriptor listed above.

I should be able to describe to anybody the patients I treat, the intervention I use and the outcomes I expect.

'Anybody' includes the following...

• the patient
• the physician
• my physical therapist and physical therapist assistant peers
• third party payers
• federal policymakers
• national and international health researchers
• rehabilitation professionals from related professions
• the man on the street (?)

If you still want to use physical therapy diagnostic labels you will have to answer Dr. Andrew Guccione's question...

"What concepts are necessary to structure clinical observations into a recognizable pattern that also suggests physical therapy intervention?"

Generally, I recommend the ICF model to any physical therapist who wants to do a good job of treating function.

Specifically, I recommend the ICF model to any private practice physical therapist who wants to generate Bulletproof Physical Therapy Notes and Charts for Medicare compliance purposes.

New Physical Therapy Medicare Progress Note

We have just updated our proprietary physical therapy Progress Note for Medicare.

The latest revision is consistent with the American Physical Therapy Association's recent endorsement of the World Health Organization's (WHO) 2001 International Classification of Function, Disability and Health (ICF).

The new Progress Note is posted at Bulletproof PT Charts.

The Progress Note is a template and is free to use.

You still have the responsibility to determine medical necessity for physical therapy, demonstrate skilled therapy and show expected improvement.

This note is just a tool to help you get there.

You have to scroll down the page a little to 'Medicare Progress Note and Re-Certification'.

You may need to modify the note to fit the needs of your PT facility.

The note is based on the ICF framework (Participation, Abilities and Body Structure/Function).

The note uses the OPTIMAL scale, baseline and follow-up, for outcomes measurement.

To learn more about a fully compliant physical therapy note and chart visit Bulletproof-PT-Charts.com.

Free free to use the note - if you have feedback either way, good or bad, please tell us to your experience.

Just comment to this blog.

Thanks.

Measurements Equals Value for Medicare

Medicare wants measurable data for a compliant physical therapy chart?

Fine.

Here's a new way to measure the strength of the external rotator of the shoulder using the common goniometer.

This measure is easy, quick and reliable (reliability data not published).

It works better than Manual Muscle Testing.

I use this measurement every day in my clinic to document the treat ment of Medicare shoulder impingement patients.

The measurements lend themselves to long term goal setting for the physical therapy chart.

I measure shoulder dysfunction in patients that some physicians don't recognize.

The measurements are accurate enough to gauge the progress of the patient.

This technique will segue to a home exercise program in a heartbeat.

I can diagnose shoulder joint stiffness.

I can diagnose shoulder muscle (ER) weakness.

You can, too.

See more simple measurement techniques at www.simplescore.com

Sign up for the free course - 'Bulletproof Physical Therapy Charts and Notes'.

APTA Endorses World Health Organization ICF Model

The American Physical Therapy Association (APTA) recently endorsed the new World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) Model.

I doubt most physicians consider disability when making a physical therapy referral.

Most medical doctors consider pathology first.

The first line intervention for pathology is usually pharmaceuticals.

Disability , and the physical impairments that lead to disability, is better addressed through physical therapy interventions such as Therapeutic Exercise (CPT 97110), Manual Therapy (CPT 97140) and other active interventions.

In the new model Impairments are replaced with 'Body Function & Structure'.

Functional Limitations are replaced with 'Activities'.

Disabilties are replaced with Participation.

Physical therapists are usually pretty familiar with the concept of disablement.

Medicare, in the United States, specifically pays physical therapists to treat disability, not pain.

The Orthopedic Section of the APTA is using the new ICF model to "Develop Evidence-Based Practice Guidelines for Treatment of Common Musculoskeletal Conditions".

The 'potential benefits of the project are to identify appropriate outcome measures'.

Currently, Medicare recommends the OPTIMAL scale for outcomes in outpatient physical therapy.

Watch OPTIMAL videos to use it for Medicare long term goal setting.

Medicare recovery audit contractors

Physical therapists are another healthcare provider that will get caught in Medicare RAC audits, as I posted on June 20th.

Medicare recovery audit contractors (RAC) draws criticism from stakeholders - 06/25/08.

The article states the following...

"The RAC, which, according to Smith, acted in an aggressive manner, also cited a lack of documentation regarding documents that the practice had provided in electronic format."

Once again, the problem stems from a lack of documentation.

Physical therapists need a simple way to document the services they provide.

Physical therapists need to quickly and accurately show the following:

1) Medical Necessity for Physical Therapy

2) Skilled Physical Therapy Services

3) Expected Improvement in a Reasonable Time Frame

How can a Physical Therapy manager do this consistently?

Get Bulletproof Physical Therapy Charts and Notes

Go to Bulletproof-PT-Charts.com

Sleep Well.