Physical Therapists use the ABN too much

Are you using the Medicare Advance Beneficiary Notice (ABN) too much?

How much is too much?

Most physical therapists' practices, in my opinion, would need infrequent use of the ABN.

I often use the the -KX but I seldom use the ABN.

How about an example?

I usually hit the physical therapy cap in 16 visits.

But now, in November 2008, I have some patients coming back to see me with multiple conditions.

They need to know if their physical therapy is a Medicare covered benefit.

So, I face the same problem you face.

I think that I might be able to help you.

What should the physical therapist do?

The routine use of the Advance Beneficiary Notice (ABN) with EVERY
patient who has $1,810 in billed charges may be inconsistent with the
design of the ABN.

With the ABN, you are saying to the patient (and Medicare):

"These services are not a Medicare covered benefit".

For example, maintenance exercise is not a Medicare benefit.

However, PT services above the annual cap ARE a Medicare benefit, if
the patient qualifies for the cap (-kx) exception.

You are the only professional in the position to determine if the patient
qualifies for the benefit.

You make your determination based on three criteria:

1) Need

2) Progress

3) Skill

In other words, does the patient need your services, can you get them
better and can you demonstrate your clinical decision-making was
necessary for their care?

Now, in November 2008, I have many patients coming back to me who have
exceeded their cap.

They may have had their rotator cuff done in February and now they
have hip pain in November.

Note: you cannot use the list of diagnoses from 2006 as the sole basis
for an automatic exception.

I usually hit the cap in 16-18 visits so patient with complex
conditions or multiple conditions will often exceed $1,810 over the
full year.

I face the same problem you face - how do I get my patients treated
and comply with Medicare rules?

Medicare doesn't know how much better patients get with PT, how bad
they were to start with or what their outcomes are.

So, I figured out a way to show Medicare.

I also made it simple for clinical physical therapists.

I designed a graph that plots all 2008 OPTIMAL functional scores on
one page. That way, when the patient comes back in October I have
their prior level of function.

I can use the graph to show a decline in function in the absence of
skilled physical therapy - that demonstrates need (medical necessity
for physical therapy).

The graph can also show the improvement from the last session of
therapy in February (expected improvement in a reasonable time frame).

Skilled decision-making is, I believe, self-evident to anyone who can
figure out the PT cap exceptions process. If not, then I have also
designed a note-writing format for my charts that prompts skilled
decisions at each visit.

Every billed charge needs to be skilled, whether you have hit the cap
or not.

Finally, the graph is simple to use, even for those of us who still
use pen and paper charts.

You can get the graph, for free, at www.BulletproofPT.com

Medicare wants you to treat patients who demonstrate need, who get
will get better and who can't do it without your skills.

The ABN is not your answer.

Try the graph and let me know what you think.

Orthopedic surgeon limits patient access to physical therapy

It's October 11th and Medicare patients are losing access to their physical therapy services.

Yesterday, I saw one of my 'snowbirds'. She is 79 years old and she spends the summer in Maine and the winter in Florida (I live in Florida).

She came in to see me in January and had rehab on her rotator cuff. Now, she is back because she fell on the golf course and injured her knee.

Her orthopedic surgeon saw her after the fall gave her a cortisone shot and four visits to therapy.

Four visits?

The surgeon didn't give her more therapy in case she needed surgery.

He explained didn't want to 'use up' her therapy by hitting the Medicare cap. He felt she would need more therapy after surgery.

The cap is a spending limit that Medicare applies to every beneficiary. This year the cap limits the beneficiary to $1,810 in billed physical therapy.

Typical physical therapy billed charges use up the cap in 16-20 visits.

Patients are coming to me now who have used up their benefit in July, or May or whenever.

What the surgeon didn't know (or didn't tell) was that the physical therapist can apply for an exception in special circumstances.

The exception is based on three simple things:

• Patient need
• Patient progress
• Physical therapist decision-making

In other words, this lady had just fallen down, she was at increased risk for future falls and she was not getting her physical therapy based on her surgeons' interpretation of the Exceptions Process to the Medicare Cap.

With all due respect, most surgeons should just stick to surgery.

Physical therapists in outpatient, non-hospital clinics can examine their patients, case-by-case, to see if the patient has characteristics that would qualify for the exception.

The fact that this surgeon was the owner of one of the largest non-hospital physical therapy clinics in the state of Florida and a direct competitor of mine may have had something to do with his 'interpretation'.

I don't know.