Can physical therapists make decisions like doctors?

Try this interactive worksheet from First Coast Service Options (FCSO) - the Medicare Administrative Contractor for A/B services for Florida. The worksheet is intended for physician training to improve correct coding of Evaluation and Management CPT codes.

I tried it.

Plug in your actions from your evaluation is the areas of History, Examination and Medical Decision Making and the Worksheet will spit out its best guess of which E/M code you should bill as if you were a physician.

The interesting thing is that my typical physical therapy evaluation corresponds to a Level 3 E/M codes (99203). Of course, physical therapists can't bill E/M codes because we are not physicians.

If you consider, however, the condition of our patients, the tests and measures physical therapists use, the complexity of our decisions and the risks we face I wonder if altering payment systems to allow PTs to bill E/M codes for certain patients makes sense?

Consider an uncomplicated ankle sprain. Evidence-based decision rules can rule out an ankle fracture with greater precision than a physician's diagnosis.

Physical therapists can refer for imaging when appropriate or treat immediately - saving costs and getting patients productive more quickly.

Similar characteristics between my PT eval and a physicians' eval include the following:

• History: Detailed
• Examination: Detailed
• Medical Decision Making: Moderate Complexity

You try it and see what you get - can you make a decision like a doctor?

Do you make doctor-level decisions?

One of the missions of this blog is to help physical therapists make better decisions diagnosing and treating your patients.

Physical therapists aim to be doctor-level decision makers but what are the differences in how physicians and physical therapists decide?

Are there similarities, too?

What are they?

This chart shows the process physicians use to decide which Evaluation and Management (E/M) code to bill.

There are three components to the physician encounter used in decision-making:

1. History
   
2. Examination
   
3. Medical Decision Making

Note that physical therapists use this same process in the initial evaluation.

History is composed of...

1. History of Present Illness
• location
  
• severity
  
• timing
  
• et al...
  
2. Review of Systems
• constitutional
  
• musculoskeletal
  
• neurological
3. Past Medical, Family and Social History

Same old, same old

So far, you and I do this every day, right?

The Examination

The examination focuses on Body Areas and Organ Systems - the more the physician examines the higher she can code.

Physical therapists usually examine back (spine), extremities, neck, maybe the abdominal body areas.

We examine 'cardio', 'musculo', skin, 'neuro', 'resp' and constitutional organ systems.

Physicians examine more areas and systems than do physical therapists and can perform 'detailed' or 'comprehensive' examinations in this part of the process.

Medical Decision Making

Three 'grids'are presented:

1. Number of diagnoses or treatment options
   
2. Amount and/or complexity of data reviewed
   
3. Risk of complications and/or morbidity or mortality

Physical therapists consider many treatment options and possible diagnoses but our limited ability to order sensitive testing and further diagnostic procedures hampers our scores on these grids - in my opinion.

Show Time

I used a 'typical' physical therapy LBP patient and went through the process - answering the questions physicians have to answer for each new (or established) patient.

History	Detailed
Examination	Expanded, problem-focused
Medical Decision Making	Moderately complex

Additionally, 'face-to-face time' may be used to determine the level of service.

One-on-one anyone?

Take Home Message

Many physical therapy lumbar evaluations may qualify for a Level 3 or 4 E/M code, if physical therapists were allowed to bill like physicians.

Take a look for yourself - do you make doctor-level decisions?