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 the OPTIMAL a subjective scale?

"It's a hurt but not a pain."

"My pain hurts when I stand at the counter to fix meals longer than five minutes."

"It gnaws and hurts and then I get angry because I can't do anything anymore!"

Physical therapists work with these folks every day.

You hear this every day.

Me, too.

Outpatient physical therapists working for Medicare are asked to quantify pain and activity limitation using baseline activity scales, such as the following:

• OPTIMAL
  
• FOTO
  
• AM-PAC
  

These scales, however, have typically been labeled as 'subjective' measures of patient function because patient self-report is not as reliable as a clinician's assessment.

Reliability is exactly the point when you see a side-by-side comparison of several traditional measures of patient illness and function.

Richard Deyo, MD originally presented data that I have reproduced here in this chart:

Reliability of Potential Outcome Measures for Back pain Trials
Type	Measure	Estimated reproducibility (test-retest correlations)
Laboratory	Spinal fluid endorphins
	Paraspinal EMG activity
Physical Measurements	Anterior spine flexion	0.50
	Passive straight leg raise	0.78
	Ankle dorsiflexion strength (dynamometer)	0.50
Function & symptoms	'Ability statements'	0.90
	Pain (VAS)	0.94

The reliability of the OPTIMAL scale is determined by a different method - a method more appropriate for studying difficulty or confidence. (Guccione et al)

OPTIMAL reliability
OPTIMAL	0.85 to 0.95

Note that the OPTIMAL is more objective than typical measures of physical function - the ones you and I learned in PT school.

Can we do better?

Sure.

As we've noted elsewhere on this blog, the OPTIMAL is a political and a policy compromise - not an academic or a clinical superstar.

But, in my opinion, using the OPTIMAL facilitates an improvement in physical therapists clinical decisions and, perhaps, the notes we write.

Since 60% of physical therapists probably don't use baseline outcome measures (Copeland, PTJ Dec. 2008) the OPTIMAL represents a 100% improvement.

The Medicare Minimum Documentation Requirements (Transmittal 88) states...

"If results of one of the ...instruments (OPTIMAL, FOTO, AM-PAC) above is not recorded, the record shall contain instead the following information..."

1. Identification of other health services concurrently being provided for this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse, respiratory therapy, social services, psychology, nutritional/dietetic services, radiation therapy, chemotherapy, etc.), and/ or


2. Identification of durable medical equipment needed for this condition, and/or


3. Identification of the number of medications the beneficiary is talking (and type if known); and/or


4. If complicating factors (complexities) affect treatment, describe why or how. For example: Cardiac dysrhythmia is not a condition for which a therapist would directly treat a patient, but in some patients such dysrhythmias may so directly and significantly affect the pace of progress in treatment for other conditions as to require an exception to caps for necessary services. Documentation should indicate how the progress was affected by the complexity. Or, the severity of the patient’s condition as reported on a functional measurement tool may be so great as to suggest extended treatment is anticipated; and/or


5. Generalized or multiple conditions. The beneficiary has, in addition to the primary condition being treated, another disease or condition being treated, or generalized musculoskeletal conditions, or conditions affecting multiple sites and these conditions will directly and significantly impact the rate of recovery; and/or.


6. Mental or cognitive disorder. The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery; and/or.


7. Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be effective, predictability of progress.

Yes, OPTIMAL measures a subjective experience...

"My leg hurts - it burns to the ankle and I can't walk!"

But OPTIMAL is an objective measure of a subjective experience - and it's helped me help my patients more.