Informed Physical Therapists Diagnose using the ICF

Informed physical therapists can make a break with 'old school' models and advance the discussion of physical therapy diagnosis by taking a look at these new APTA resources for the new International Classification of Functioning.

'Old School' models, many of which I have used, include most of the mechanistic models we learned in PT school and at 'Hilton University' (some of you may have gone to 'Marriott U' or 'Holiday Inn U').

To name a few...

NDT
PNF
McKenzie
Maitland
Mulligan
Paris
The Facet Joint
The Disc (...is a jelly doughnut)
Sacroiliac joint
McConnell taping

Now, with ICF, you can abandon models and just treat the patient.

This new paradigm (new to me since 2001) allows the physical therapist to measure characteristics of the patient that may impact function and apply treatments without regard to the mechanism.

Ah, freedom.

Freedom from justifying my treatments to other PTs, PTA's, patients or payers. If I get my patient better - who cares how I did it or what technique I used?

The power in the ICF model is that I can find freedom while a different PT or PTA can find meaning in a different way.

The ICF is a framework - not a blueprint.

I practice orthopedic PT but the ICF is equally appropriate for neuro PTs.

Use my templates and watch my videos to see how I use the ICF to inform PT orthopedic decision-making.

The New Physical Therapy

"All models are wrong, but some are useful" begins the Wired Magazine article The End of Theory.

The article, by Chris Anderson (of The Long Tail fame), goes on to explain that in this current 'era of massively abundant data' scientists have become less reliant on the age old tradition of creating plausible models and testing hypotheses to refute or deny the model.

Instead, scientists can merely find correlations is massive data sets that have been, heretofore, unavailable for study and searching.

The power of sufficient data allows us to say "Correlation is enough" (Anderson).

Physical therapy has embraced this new thinking since 2002.

A manipulation decision rule was published in Spine magazine that laid out 5 predictor variables PT clinicians could test for: the presence of 3/5 variables implied that the patient was a good candidate for manipulation.

Anderson states that massively abundant data

"forces us to view data mathematically first and establish a context for it later."

The researchers first measured their physical therapy patients with dozens of 'traditional' physical therapy test and measures.

They then dumped the results of these measurements (some good, some bad) into a statistical 'hopper' and compared the results with the patients that got better.

Those tests that best predicted the patients that got better were the final predictor variables.

To paraphrase Anderson...

Who knows why patients get better? The point is that patients do get better and we can track and measure those patients with increasing accuracy.

"With enough data, the numbers speak for themselves"

Measurements are the key, however. Without measurements we cannot draw correlations.

Even Google could not search web pages if no one bothered to post their data.

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'.

Physical Therapy's Unholy Alliance

This post well-summarizes the recent House and Senate vote on the Medicare Physician's Fee Schedule.

My response to the post recommends ending or reducing not only the bi-annual Medicare lobbying bonanza and PAC funding spree but also the "unholy alliance between providers, payers and patients" (I'm quoting myself).

Here is the response from the American Medical Association to Friday's Senate vote:

***

Statement Attributable to:
Nancy H. Nielsen, M.D.
President, American Medical Association

"The physicians of America are outraged that a group of Republican senators followed the direction of the Bush Administration and voted to protect health insurance companies at the expense of America’s seniors, disabled and military families.

"These senators leave for their 4th of July picnics knowing that the most vulnerable Americans are at risk ...

"...Today, thanks to some senators, we stand at the brink of a Medicare meltdown. On July 1 – just four days from now – the government will slash Medicare physician payments by 10.6 percent, forcing many physicians to make the difficult choice to limit the number of Medicare patients in their practices.

"The Senate must return from their recess and make seniors’ health care their top priority. For doctors, this is not a partisan issue - it's a patient access issue."

***

(here I respond to her original post)

While I agree with the facts of your post I wonder if the rhetoric of the AMA well serves the American public (especially the 46 million uninsured, mainly women and kids).

Instead of bi-annual(we went through this in December 2007 - remember?) 10% Medicare cuts why not a 2% annual reduction in the Medicare Physician's Fee Schedule?

Everyone knows the direction federally funded healthcare reimbursement has to go.

Large cuts inevitably trigger PAC funding and large-scale lobbying to reduce or reverse the cuts.

More money is not the answer.

One solution to the healthcare "crisis" is to dissolve the unholy alliance of providers, payers and patients.

-----------------------------------------

Can patients afford healthcare without heavy regulation and government intervention?

That is, would there be a healthcare system without insurance companies and Medicare?

Many economists don't think so.

Nevertheless, physical therapy is well-suited to provide services to patients in gyms, schools, industry workplaces and to private-pay, 'cash practices' that would avoid the need for the third party arrangement that dominates healthcare today.

Physical therapists provide value with every intervention.

See how to provide valuable, audit-proof physical therapy for Medicare patients in outpatient physical therapy clinics.

Is Physical Therapy Valuable?

Physical therapists think that Medicare is run by bureaucrats (it is) but Medicare physical therapy policy is also set by bureaucrats (it isn't).

Years ago, I graduated from the University of Florida Physical Therapy Program with a Bachelors Degree in Health Science. I was trained in orthopedics and neurology. I was not trained in Medicare.

To get information from Medicare, in 1992, you had to do the following:

• call on the telephone


• ask your question


• wait while the bureaucrat looked up your answer in the Medicare Manuals


• gave you their interpretation


• implement your policy change

Fast forward to 2008 when, if you have a question about Medicare, you can open your handy electronic copy of Transmittal 88 using the Adobe Acrobat Reader (available for free) and plug in your question to the search bar.

Curious about Medical Necessity for Physical Therapy?

What exactly do the regs say?

A quick search (<5 seconds) returns 10 instances of 'Medical Necessity' in Transmittal 88. That should get you started.

But my original premise is that many physical therapists think the Medicare Manuals are written by bureaucrats without the patients' best interests at heart.

Why should physical therapists pay attention to policy written by bureaucrats (other than the police powers exercised by Medicare)?

Pay attention to this post by Larry Benz,PT posted at the Yahoo Groups PT Manager listserve

"The medicare superimposed rules have been written by beaurocrats (sic) and our profession has acquiesced or have had "small victories" that have been alluded to that only refine them.


At the end of the day, these additional "standards" cause increased monitoring costs and take away time from patients.
If the over regulated medicare rules become de facto as is being pursued by multiple folks within the PT world, there will not be a viable outpatient PT economic model."

The obvious answer is that bureaucrats don't write Medicare regulations in a vacuum.

Medicare consults with physical therapists like Rick Gawenda, President of the APTA Section on Administration and Steve Levine of the Rehabilitation Consulting and Resource Institute to implement changes to there Manual system.

The three 'bottom line' criteria that define a compliant Medicare plan of care are these:

1) Can the physical therapist demonstrate the medical necessity for physical therapy?

2) Can the physical therapist (or the PTA) demonstrate skilled therapy for each billed procedure?

3) Can the physical therapist show an expectation of a significant improvement in measurable patient function n a reasonable time frame?

If you do good PT the first time then there are no 'increased monitoring costs'.

Good PT begins with Physical Therapy Diagnosis, just like the physicians do it.

“Medicare changes every year”

In 2006, Medicare issued three new transmissions that altered the technical language of the Benefit Policy Manual.

In 2007 Medicare issued no new transmissions that altered the technical language of the Benefits Policy Manual.

In 2008 there will likely be one transmittal in February that will alter the language of the Benefits Policy Manual. The alteration mainly deals with the new ninety (90) day re-certification period.

Nevertheless, the myth among many physical therapists and physical therapist assistants is that Medicare changes every year and, as a result, there is no way to understand or to predict the seemingly random and haphazard changes in the rules.

I've noticed this belief among physical therapy students and physical therapy educators. There appears to be a reluctance to instruct students in the basic requirements to treat Medicare patients.

These requirements are the folowing:

Demonstrate the Medical Necessity of Physical Therapy

Demonstrate that you expect the patient to recover significant function in a reasonable time frame.

Demonstrate skilled physical therapy services.

If new graduate physical therapists and educators focus instead on the process of physical therapy diagnosis and on the needs of the patient then the technical requirements for treating Medicare patients may seem less burdensome.


The patients’ needs never change

While the technical requirements of treating the Medicare beneficiary do change and these changes seem to have less to do with physical therapists’ job demands and more to do with policy or political machinations at the national level it is important to remember that the patients’ needs never change.

The premise of the SIMPLE system is physical therapy diagnosis leads to good documentation and that ongoing assessment requires a written record of prior measurements.

Goal setting and the selection of interventions is a logical, predictable process predicated on the findings in the evaluation.

Physical therapy diagnosis is a process, not an event.

The initial diagnosis is often based on incomplete data that may be refined or changed by the time the discharge note is written. The diagnosis in the discharge note may be the same or it may be entirely different from the initial diagnosis.

When physical therapists understand that Medicare pays for (and demands documentation that demonstrates) the ongoing assessment and ultimate diagnosis of the physical therapist then the technical changes are less relevant to the process.

The process never changes.

How to Write a Medicare Progress Note

As of January 1 2008 re-certifications have to be written every 90 days, up from 30 days in 2007.

Medicare no longer views the physician signed approval of the plan of care as necessary and sufficient to prevent over-utilization. Now, as always, the physical therapist is responsible for providing the appropriate amount of physical therapy services.

The difference now is there will not be a signed note every month from the doctor that ‘tells’ the physical therapist to do physical therapy. There will only be the clinical decision-making of the physical therapist.

When reviewing the physical therapists notes in the chart to determine if the services provided were appropriate, Medicare auditors will look at three things, primarily.


1. Were the services Medically Necessary?

2. Were the services delivered skilled? That is, could a lesser-trained person (such as an aide) have delivered the services at less cost to the Medicare program?

3. Did the patient improve the expected amount in a reasonable time frame?


The physical therapist can write the re-certification note so as to demonstrate these three criteria.

Prior to 2008, many facilities did not distinguish between the Re-certification Note and the Progress Note.

Prior to 2008, the Progress Note was due every ten treatment sessions or once per month, whichever was less.

Prior to 2008, the Re-certification Note was due every ten treatment sessions or every calendar month, whichever was greater.

In 2008, the requirements for the Progress Note have not changed but the Re-certification is now only required every 90 days.

Start the Note

Just as you would in the evaluation, start the Progress Note with a Re-evaluation.

First, measure the Functional Limitations with the OPTIMAL (Outpatient Physical Therapy Instrumented Movement Assessment Log). See this video for the exact way to use the OPTIMAL score sheet.

Specifically, check the patient-identified limitations that they would most like to see improved. Compare them with their initial scores.

Have you set long-term goals using functional limitations? If so, has the patient met their goals?

Next, measure the impairments in range-of-motion that you linked to functional limitations in your initial physical therapy diagnosis. Compare the new measurement with the initial measurements. Did you set goals for these impairments? Did the patient meet their goals?

Finally, check off the goals that have been met and set new goals. If you recommend the patient continue physical therapy then you should set new goals. Remember, you want to demonstrate significant improvement in an expected time frame. The new goal should still reflect the expected time frame you identified in your evaluation.

An Example

For instance, the initial goal was to improve OPTIMAL overhead lifting (frozen shoulder) from a 4/5 to a 2/5. You spent 4 weeks doing stretching and PROM and the patient can now passively range her arm overhead. You might set the new goal to increase external rotator muscle strength from X to Y (see this video for the exact technique to measure external rotator muscle strength).

Now the physical therapist must sign the note. The PTA cannot write the Progress Note. The PT must see the patient at least once during the 10 session treatment period and the Progress Note session is sufficient.

SIMPLE Describes Low Back Pain

The SIMPLE movements reflect a common problem.

The SIMPLE movements were derived from my observation that many patients in my practice suffered from disordered movement patterns that result from and contribute to lumbar spinal stenosis.

The interesting thing that I noticed after I had started to gather the data was that many patients who had not (yet) developed radiographic evidence of stenosis, nevertheless, displayed many of the same impairments in strength and range of motion as those patients who had a medical diagnosis of spinal stenosis from their physician.

Low back pain is an endpoint and lumbar spinal stenosis is the last step in the degenerative cascade that originates with disordered movements in our earliest years.

Patients present to many practitioners at points along the way to their penultimate point and it is my hope that SIMPLE can be used to describe the physical dimension of those points.

In my naiveté I persist in believing that if we can describe a physical process then we can change it.

SIMPLE Bias

At this point I should acknowledge an obvious bias in the SIMPLE system: an exercise bias.

SIMPLE is designed to provide the physical therapist with goals and interventions that are amenable to therapeutic exercise and (to a lesser extent) manual therapy.

This bias is not accidental.

The physical therapy profession is well positioned to lead the public in modern exercise attitudes and in movement awareness. Exercise is very nearly synonymous with the phrase ‘physical therapy’.

The connection between exercise and physical therapy exists, not because of advertising and marketing, but because of a real need and a demand for skilled exercise services.

The connection between exercise and physical therapy is not complete since the association with exercise is ‘flavored’ by athletic trainers, personal trainers, exercise physiologists, aerobics instructors, coaches and fitness gurus.

To control the domain of exercise then physical therapists need to measure movement.
If a physical therapist can tell their patient the exact amount and quality of their existing movement impairment then the physical therapist can prescribe exercise precisely to correct the impairment.

To measure movement physical therapists need simple and precise tools that determine the extent of their patient’s involvement and that can help decide the proper intervention.

In Outpatient Physical Therapy for Musculoskeletal Conditions, Stephanie Carter, PT, PhD says the following:

“It is not known how many people with musculoskeletal conditions actually need physical therapy services, and no criteria exist for making this determination”8

SIMPLE is predicated upon the following assumption:

The presence of impairments (with or without pain) should be the criteria for determining those people who need skilled exercise intervention.

The role of SIMPLE is to help physical therapists measure the presence or the absence of impairments that affect physical function and thereby become better decision-makers and better diagnosticians.

To physical therapists, physical therapy is much more than just exercise.

To physical therapists’ patients, however, physical therapy is just what physical therapists do.

The patient doesn’t know the difference and the patient doesn’t care.

The patient just wants to get better.

Tim

Physical Therapist Doctor

It's December 27th 2007 and Physical Therapists are required to make physician-level decisions.

Physical therapists are required to determine the Medical Necessity for Physical Therapy as part of the physical therapy plan of care.

This level of decision-making requires a physical therapy diagnosis, assessment of physical impairments, functional limitations, patient co-morbidities and intangibles like motivation and aptitude.

Just like a medical doctor has tools like x-ray, MRI and blood tests to make the diagnosis the physical therapist needs tools to make the physical therapy diagnosis.

To learn how to assess physical impairments in range-of-motion and strength go to www.SimpleScore.com and view treatment videos.

Tim