Answers about Physical Therapy Functional Status Measures

I'm listening to the National Provider Call that covers the new functional reporting requirements for outpatient therapy services, including physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services, effective January 1, 2013.

Here is the presentation.

I notice that many of the participants questions that follwoed the presentation are answered in the links provided at the bottom of the National Provider Call-in page. You can go there now and download the material if you haven't already done so.

The new, non-payable G-codes will be a big hurdle for physical therapists, especially the small, outpatient physical therapist who spends his or her whole day treating patients.

I encourage you to review the CMS material. Also, reach out ot your friends and peers to see how they are handling this burden in their practice. E-mail me if I can help at my e-mail address.

Also, an e-mail mailbox has been created to answer questions related to Functional Status Reporting for Therapy Services at TherapyServicesNPC@cms.hhs.gov.

Is the Severity-Intensity Model a Roadmap for Fraud and Abuse?

First, I'd like to thank all the hard-working staff and volunteers at the American Physical Therapy Association (APTA) for the effort that went into developing the Severity-Intensity Model, also known as the Alternative Payment System (APS).

Like them, I'd like to see payment reform. But, I want reform that preserves the autonomy of the therapist-patient collaboration rather than depends on centralized oversight of physical therapists by government regulators.

I'm afraid the Severity-Intensity Model may just increase the ability of regulators to audit physical therapists.

Physical therapists are set-up to fail, in every setting, by a documentation framework that was never intended to capture the patient experience of chronically disabled adults.

The Physical Therapy Business Alliance keyed-in on a central flaw in Severity-Intensity in its post at EIM on June 13th, 2012:

"However, the APS in its current form disproportionately emphasizes administrative and regulatory requirements (ie, documentation, compliance, etc.) at the expense of the most critical elements of the clinical encounter, which is incentivizing quality clinical outcomes and patient satisfaction."

We're not alone - this telling indicator of professional consensus is the OVERWHELMINGLY NEGATIVE comments posted at the PTinMotion web site in response to an article on the Severity-Intensity model.

Severity-Intensity Would Increase "Fraudbusting", not fraud
This chart is derived from the Development Draft for APTA Members: An Alternative Payment System for Physical Therapy Services - APTA members have until Friday, June 22nd to comment.

Go to this link and add your two cents.

Recommended Times for Severity-Intensity Patient Visits
	Patient Severity at the time of the Visit
Intensity of Therapist Decision Making	Limited	Moderate	Significant
Limited	30 minutes	30 minutes	30 minutes
Moderate	31 - 45 minutes	31 - 45 minutes	31 - 45 minutes
Significant	45 minutes	45 minutes	45 minutes

The yellow cells are 1-on-1 codes that require individualized interaction between the qualified healthcare professional and the patient.

We all think OUR patients are more difficult to treat than our fellow therapists' patients - this is true in medicine too and is known as Response Bias (seeing what you expect to find). Therefore, using Severity-Intensity we would expect to see a "southeast shift" in coding based on this chart - every patient belongs in the yellow highlighted cells. 

"Code inflation" would occur, based on coding and reimbusement seminars promoted by "Medicare Experts" - here's an example I received yesterday in my e-mail:

"Treatment consists of manual therapy, 97140, to reduce swelling and scar formation followed by passive, active assistive ROM exercise to improve ROM at the knee; 97110, quad sets, SAQ, and SLR to promote the efficiency of the quad contraction and promote quad control at the knee joint, 97112; and finally, I want to put it all together by working on sit to stand transfers emphasizing knee flexion in sitting and equal weight distribution in sit to stand and stand to sit, 97530."

Really?

Is this what we want Doctors of Physical Therapy spending their time on in the 21st century? Writing this blah-blah-blah?

I think your time, and mine, is more valuable than that.

And, technology is increasingly bringing us better documentation alternatives.

Severity-Intensity just adds a layer of complexity on top of the flawed documentation framework that wastes so much time and physical therapist productivity.

What Now?
The Severity-Intensity Model needs to be accepted by the American Medical Association Relative Value Update Committee (AMA RUC) which may then recommend Severity-Intensity to the Centers for Medicare and Medicaid Services (CMS) to be used within its Current Procedure Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) IN PLACE OF the CPT 92505-97799 codes (also a few G-codes and a few others, possibly).

What Do We Use Instead of Severity-Intensity?
The American Academy of Family Physicians (AAFP) has proposed to the Congress a primary care-based Medical Home Model which pays primary care physicians three ways:

• Fee for Service for each individual procedure
• a care management fee that compensates for expertise and time such as management and care coordination that are not direct patient encounters
• Pay for performance based on hitting benchmarked process and outcome measures

I believe the way forward for physical therapists is to move "upmarket", in the words of disruptive innovator Clayton Christensen, and compete directly with primary care physicians for the care of musculoskeletal conditions.

27 New Medicare Accountable Care Organizations Open April 1st, 2012

NEW AFFORDABLE CARE ACT PROGRAM TO IMPROVE CARE, CONTROL MEDICARE COSTS, OFF TO A STRONG START OVER 1.1 MILLION BENEFICIARIES NOW SERVED BY ACCOUNTABLE CARE ORGANIZATIONS

A new program that will help physicians, hospitals, and other health care providers work together to improve care for people with Medicare is off to a strong start, the Centers for Medicare & Medicaid Services (CMS) announced today.

Under the new Medicare Shared Savings Program (Shared Savings Program), 27 Accountable Care Organizations (ACOs) have entered into agreements with CMS, taking responsibility for the quality of care furnished to people with Medicare in return for the opportunity to share in savings realized through improved care. The Shared Savings Program and other initiatives related to Accountable Care Organizations are made possible by the Affordable Care Act, the health care law of 2010. Participation in an ACO is purely voluntary for providers and beneficiaries and people with Medicare retain their current ability to seek treatment from any provider they wish.

The first 27 Shared Savings Program ACOs will serve an estimated 375,000 beneficiaries in 18 States. This brings the total number of organizations participating Medicare shared savings initiatives on April 1 to 65, including the 32 Pioneer Model ACOs that were announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011. In all, as of April 1, more than 1.1 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

"We are encouraged by this strong start and confident that by the end of this year, we will have a robust program in place, benefitting millions of seniors and people with disabilities across the country," said CMS Acting Administrator Marilyn Tavenner.

Anyone who has multiple doctors may have experienced the frustration of fragmented and disconnected care: lost or unavailable medical charts, trouble scheduling an appointment or talking to a doctor, duplicated medical procedures, or having to share the same information over and over with different doctors.

Accountable Care Organizations are designed to lift this burden from patients, while improving care and reducing costs. The Shared Savings Program was created by the Affordable Care Act after a number of efforts in the private sector showed that improving care can lead to lower costs. The selected ACOs include more than 10,000 physicians, 10 hospitals, and 13 smaller physician-driven organizations in both urban and rural areas. Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving. CMS is reviewing more than 150 applications from ACOs seeking to enter the program in July.

To ensure that savings are achieved through improving and providing care that is appropriate, safe, and timely, an ACO must meet strict quality standards. For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and the patient and caregiver experience of care.

CMS also announced today that five ACOs are participating in the Advance Payment ACO Model beginning April 1. This model will provide advance payment of expected shared savings to rural and physician-based ACOs participating in the Shared Savings Program that would benefit from additional start-up resources. These resources will help build the necessary care coordination infrastructure necessary to improve patient outcomes and reduce costs, such as new staff or information technology systems. CMS is reviewing more than 50 applications for Advance Payments that start in July.

LIST OF ACCOUNTABLE CARE ORGANIZATIONS STARTING APRIL 1, 2012

1. Accountable Care Organization/Collaborative Health Systems Partnerships
2. Accountable Care Coalition of Caldwell County, LLC Lenoir, NC
3. Accountable Care Coalition of Coastal Georgia Ormond, FL (Serving beneficiaries in GA and SC)
4. Accountable Care Coalition of Eastern North Carolina, LLC New Bern, NC
5. Accountable Care Coalition of Greater Athens Georgia Athens, GA
6. Accountable Care Coalition of Mount Kisco, LLC Mount Kisco, NY
7. Accountable Care Coalition of the Mississippi Gulf Coast, LLC Clearwater, FL (Serving beneficiaries in the Mississippi Gulf Coast area)
8. Accountable Care Coalition of the North Country, LLC Canton, NY
9. Accountable Care Coalition of Southeast Wisconsin, LLC Milwaukee, WI
10. Accountable Care Coalition of Texas, Inc. Houston, TX
11. AHS ACO, LLC Morristown, NJ (Serving beneficiaries in NJ and PA) AppleCare Medical ACO, LLC Buena Park, CA
12. Arizona Connected Care, LLC Tucson, AZ
13. Chinese Community Accountable Care Organization New York, NY
14. CIPA Western New York IPA, doing business as Catholic Medical Partners Buffalo, NY
15. Coastal Carolina Quality Care, Inc. New Bern, NC
16. Crystal Run Healthcare ACO, LLC Middletown, NY (Serving beneficiaries in NY and PA)
17. Florida Physicians Trust, LLC Winter Park, FL
18. Hackensack Physician-Hospital Alliance ACO, LLC Hackensack, NJ (Serving beneficiaries in NJ and NY)
19. Jackson Purchase Medical Associates, PSC Paducah, KY
20. Jordan Community ACO Plymouth, MA
21. North Country ACO Littleton, NH (Serving beneficiaries in NH and VT)
22. Optimus Healthcare Partners, LLC Summit, NJ
23. Physicians of Cape Cod ACO
24. Premier ACO Physician Network Lakewood, CA
25. Primary Partners, LLC Clermont, FL
26. RGV ACO Health Providers, LLC Donna, TX
27. West Florida ACO, LLC Trinity, FL

Get the CMS fact sheet

12 weeks of Physical Therapy Required By New Medicare Guidelines Prior to Joint Replacement in Florida

Medicare has begun to deny hospital charges for total joint replacement surgery IF the surgeon has failed to implement up to 12 weeks of pre-operative PT and/or bracing, according to Vincent Hudson, CEO of the medical consulting practice PMC, Inc.

"Medicare A has denied payment to hospitals, and I am sure will trickle over to physicians.  

This new standard should be increasing the numbers of referrals we see from Medicare.  

As in most cases, I expect to see other commercial insurances to follow shortly.  

Make your referring physicians aware of this, as hospitals have already begun to do so..."

Vincent made his comments on March 20th on LinkedIn in the Physical Therapists in Private Practice group.

This agressive new program in Medicare Audits is threatening physician and hospital reimbursement for total joint replacements and lumbar spine fusion in many states across the country.

The expanded use of Medicare Administrator Contractor (MAC) pre-payment audits has placed a premium on documentation in the hospital record and may threaten reimbursement for physicians with poor documentation skills.

On November 15, 2011, CMS announced three new 3-year demonstration projects (reported here by PTD). The Recovery Audit Prepayment Review Demonstration is designed to help curb improper Medicare and Medicaid payments.

As proposed, the demonstration would allow Medicare recovery auditors to review claims after services are provided but before the claims are paid to ensure that the provider complied with all Medicare payment rules. This would prevent improper payments before they are made.

Seven states with high populations of fraud- and error-prone providers are targeted

1. Florida
2. California
3. Michigan
4. Texas
5. New York
6. Louisiana
7. Illinois

...and four states with high claims volumes of short inpatient hospital stays are targeted.

1. Pennsylvania
2. Ohio
3. North Carolina
4. Missouri

As designed, this program would affect almost half of the Medicare population.

The contractor for MAC jurisdiction 9 is First Coast Service Options (FCSO), which includes Florida, Puerto Rico, and the Virgin Islands. FCSO developed a local coverage determination (LCD) on total joint replacements.

The original draft LCD included a requirement that multiple 12-week nonsurgical interventions, such as physical therapy, be documented prior to surgical total joint replacement.

Revisions to the LCD now require only one non-surgical intervention, such as 12 weeks of physical therapy.

Weeks later, the MAC announced a new prepayment audit of 15 specific DRGs, 4 of which are orthopaedic codes, including those that cover total joint replacements.

"As with the Total Knee replacement, the medical record documentation must indicate continued symptoms following medication ....there also must be documentation of a trial of physical therapy and/or external joint support provided equal to or greater than 12 weeks..."

I agree with Vincent.

Get out there and educate your physicians, especially your family practice docs and your unaffiliated orthopedic surgeons who will want to avoid denials.

They'll appreciate the heads-up.

Error Rate Among Medicare Auditors High

Recovery Audit Contractors (RAC) have recovered more dollars in 2011 than they did in 2010 but this metric of success may overstate their value.

A Washington Post story from yesterday, November 14 2011, shows that Medicare auditors make overpayment determinations based on "inaccurate data".

RAC activity in 2011 was centered in the West and the Southern United States.

State	Overpayment
Florida	$7.1 million
California	$7.7 million
Washington	$5.3 million
Texas	$5.8 million

"The error rate in the Medicare RAC process is disturbingly high, especially since the cost of filing an appeal can be prohibitive," said AMA President Peter W. Carmel, MD.

"The AMA is working with CMS to improve this process and decrease the financial and administrative burden on physicians."

A 2010 Office of the Inspector General (OIG) report found that CMS...

"...did not sufficiently oversee the RACs during the demonstration project to ensure the vulnerabilities pursued by RACs were valid and that RACs made accurate improper payment determinations.

According to provider associations, this led to numerous appeals of inaccurate RAC determinations that were expensive and burdensome for providers."

Physical therapists can reduce their risk of a RAC audit, or any Medicare audit by following the seven components of the OIG Compliance Program for Individual and Small Group Physician Practices.

Also, join the email tutorial in the sign-in boxes above or below this post.

Comparative Effectiveness Research under attack

Physical therapists who support research comparing surgical interventions with physical therapy for chronic, painful spinal stenosis are under attack.

A group of 56 congressmen have written a letter asking President Barack Obama to withdraw the nomination of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS).

Their opposition to Dr. Berwick is based on his support of Comparative Effectiveness Research. The congressmen who wrote the letter are House Republicans not involved in Dr. Berwick's upcoming Senate confirmation meeting. They called Dr. Berwick's beliefs "rationing":

“We believe that Dr. Berwick’s recommendation for the federal government to use ration-based, cost-effective research to restrict patients’ access to medically necessary care is wrong.”

...the letter said.

But, according to White House spokesman Reid H. Cherlin,

“The fact is, rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need.

Don Berwick wants to see a system in which those decisions are transparent – and that the people who make them are held accountable".

The White House continues to support Dr. Berwick who was nominated April 19th. His Senate confirmation hearing has yet to be scheduled.

There is ample need for head-to-head studies examining both the indications for and the outcomes the following:

• surgery for lumbar spinal stenosis,
• all treatments for lower back pain,
• diagnostic imaging

Spine fusions alone cost Medicare $575 million dollars in 2007. That money would buy a lot of physical therapy.

Who can think of other, promising areas where PT might compare favorably with dangerous and expensive surgical options?

Overheard at the CMS watercooler...

Overheard at the watercooler at the Centers for Medicare and Medicaid Services (CMS)...

Hmm,

In-person contact and proactive advice on exercise could reduce Medicare hospitalization and reduce costs, according to this February 11th JAMA article.

I wonder where we could get in-person contact and proactive advice on exercise?

Maybe using physical therapists as primary care providers would save money!

I couldn't hear the rest of the conversation between the CMS staffers but, as they walked back to their desks I heard one of them exclaim loudly,

"...this study offers ... important insights to guide Medicare policy on coordination of chronic disease care going forward.

“... care coordinators must interact in person with patients and not simply educate or assist them by telephone. Only 4 of the 15 programs emphasized in-person contact between coordinators and participants..."

I hope those staffers have some influence with their bosses - so physical therapists get better positioned to help our patients with exercise advice and save some money.

Would most physical therapists in the United States feel comfortable in a primary care role, giving advice to patients?

What do you think?