Outpatient physical therapy and 17-page Medicare Evaluations

Outpatient physical therapists get ready - you may soon have to perform 17-page Medicare initial evaluations like your brothers and sisters in home health care.

The project Developing Outpatient Therapy Payment Alternatives (DOTPA) has issued these evaluation forms as 'prototypes' - presumably for provider input.

The proposed evaluation forms are available from the Research Triangle International (RTI) website - get the eval and discharge for institutional settings (eg: nursing facilities) (25 pages) and for community based settings (eg: PTPP).

The outpatient PT discharge note is only 16 pages. Yippee!

The point of this new 'provider burden' is to change the Medicare payment system to a 'value based' system where physical therapists are paid based on the 'risk adjusted' complexity of the patients we see.

For example, if you see a 75-year old patient with the following:

• lower back pain
• high fear avoidance beliefs
• depression
• lives alone
• smokes and drinks alcohol
• appears to have limited understanding/awareness of their health condition and its possible outcomes

...you may be entitled to higher payments based on these listed risk factors.

I say may because no one knows what this alternative payment system will look like.

Currently, the OASIS (Outcome and Assessment Information Set) outcome data does not appear to show outcomes ranked by risk factor.

The most relevant outcome for outpatient care - number of visits - is obviously not as relevant to home health care so we couldn't expect guidance on number of visits.

Utilization outcomes for OASIS instead look at the following:

• Received Emergency Care
• Discharged (home) from Home Health Care
• Admitted to an Acute Care Hospital

OASIS also shows outcomes ranked by state as the percentage of patients who 'improved' - for example:

...of the home health care patients treated in Florida treated between June 2007 and June 2008:

• 46% improved in their ability to walk
• 27% were re-hospitalized
• 17% went to the emergency room prior to discharge

I have a few questions for RTI before they recommend that Medicare implement a 17-page OASIS-style eval/discharge assessment in outpatient physical therapy.

1. What is 'improved'?
2. How far did they walk?
3. How fast did they walk?
4. Are they satisfied with their home health care?
5. How long did the episode of care last?
6. How much did it cost?

Brothers and sisters, what questions do you have?

Own Your Own PT Clinic

Own your own PT clinic.

Owning your clinic is the dream of many smart, young physical therapists.

Treat how you feel your patients should be treated.

Do good work.

Get paid.

That's how I got started.

But I started with partners and I bought them out.

Out with the old and in with the new.

That's what I thought, at the time.

It was all mine.

*****

Then I looked around.

And there it was...

Something old, still there.

Sitting on the shelf, dusty.

An old three-ring binder.

Pages yellow with age.

When I opened it, I sneezed.

Dust flew off of the page, around my eyes.

It was the old clinic Medicare compliance manual.

Never opened.

Never updated.

Inside were ten, yellow typewritten pages.

Typewritten... On a typewriter.

The Manual

The pages contained, believe it or not, instructions on how to assemble hot packs and instructions to aides on how to treat patients.

There was actually a copy of a referral pad with a physicians' signature line that stated the following:

"These treatments are Medically Necessary for the patient to receive physical therapy services."

There was a diagram of the floor plan with the fire escapes marked in faded red marker.

The manual had one page that told what to do in the event of a hurricane.

It had another page that listed vacation days.

Wow.

The Date

I found a date.

1988.

That's when I started to panic, a little.

My Action Plan

I decided to get busy building a plan.

I took a seminar by an expert Medicare consultant.

According to the expert, my notes were so far out of compliance there should have been a red, neon label that said "Audit Me!" attached to every charge I sent to Medicare.

That's when I started to panic, a lot.

I decided to learn everything I could about outpatient physical therapy Medicare compliance.

I took more seminars, bought books, read newsletters, called my practice association and, in general, specialized in outpatient physical therapy Medicare compliance.

I excitedly went to my staff, 7 PTs and PTAs.

I told them everything I had learned.

You know what happened?

Big yawn.

Some PTs and PTAs fell asleep during my presentation.

Some were more polite about their disinterest.

Bottom line, the notes and charts didn't get much better.

Why?

It didn't matter.

I hadn't shown my staff why and how Medicare compliance made better physical therapy.

I hadn't shown my staff how they could help their patients more with better notes.

My PTs and PTAs just wanted to treat patients.

They couldn't see why and how notes could help them do that.

I had to do better.

I went back to the drawing board - I made Bulletproof Physical Therapy Notes and Charts.

Bulletproof is uses three, public-domain tools to show physical therapists' decisions - the core of your skill set.

Bulletproof uses templates to show progress and need for PT.

Bulletproof also describes dozens more tips, techniques and strategies for physical therapist mangers and educators to train PTs and PTAs to get Bulletproof Notes and Charts.

There is no three-ring binder to keep from getting dusty.

So far, the results are very encouraging.

My staff and my patients are happier than ever.

We are confident now when we append the -kx modifier, start a second month of therapy or just write a daily note.

Now, I'm not scared anymore.

Finally, I'm living the dream.

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.

Medicare Fraud Strike Force Indicts Eight in Miami

So far this and other Medicare actions in the South Florida area do not appear to have involved physical therapists.

The Medicare Fraud Strike Force arrested eight individuals in October 2008, including two doctors, charging them with conspiracy and fraud in a scheme to bill Medicare for HIV infusion treatments that were never performed.

Similar schemes involving compounding pharmacies in 2007 cost the Medicare program $20 million dollars.

In May 2007 a Miami medical billing company was convicted of fraudulently collecting $56 million from Medicare.

Medicare payments to home health agencies in Miami have increased 1300% since 2003.

Medicare is...

"focusing on home health agencies that send nurses to give homebound diabetics insulin injections. Some patients are neither homebound nor unable to give themselves the injections...Some don't even have diabetes."

So, how does this affect physical therapists?

All health care providers are suspect when these kinds of abuses occur.

Medicare must enact tougher controls to manage the system.

Better control of 'outlier' payments is first on Medicare's list.

From the October 10, 2008 USA Today -

"Randall Culp, an FBI agent who oversees a team that investigates Medicare fraud, says Medicare should move faster to revoke Medicare status for questionable home health agencies and crack down on outlier payment abuses."

If you are a legitimate outlier, for instance a manual physical therapist who charges a lot of Manual Therapy (CPT 97140) you need to make sure that your notes support your billed charges.

You need to show...

• Medical necessity for physical therapy (measurable, treatable findings)
• Expected improvement in a reasonable time frame (progress)
• Skilled physical therapy (decisions)

A legitimate outlier would have a patient population that requires above-average amounts of a particular intervention, for instance chronic low back pain.

Documented pain diagrams or patient-reported functional scales, such as the OPTIMAL can help demonstrate medical necessity for physical therapy for this patient population.

Validated outcomes measure such as OPTIMAL or AM-PAC can show progress.

Skilled therapy is demonstrated by your decisions.

Get training for improved physical therapy decision making at BulletproofPT.com.

Outpatient physical therapists under scrutiny by Office of the Inspector General

The OIG 2009 Work Plan has several areas that address outpatient physical therapists directly.

• Outpatient Physical Therapy Services Provided by Independent Therapists

"We will review outpatient physical therapy services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 220.3, contains documentation requirements for therapy services. Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with Federal requirements.
(OAS; W-00-09-35220; various reviews; expected issue date: FY 2009; new start)"

• Physicians’ Medicare Services Performed by Nonphysicians

"We will review services physicians bill to Medicare but do not perform personally. Such services, called “incident to,” are typically performed by nonphysician staff members in physicians’ offices. The Social Security Act, § 18610(s)(2)(A), provides for Medicare coverage of services and supplies performed “incident to” the professional services of a physician. However, these services may be vulnerable to overutilization or put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. We will
FY 2009 OIG Work Plan 15 Centers for Medicare and Medicaid Services
examine the qualifications of nonphysician staff that perform “incident to” services and assess whether these qualifications are consistent with professionally recognized standards of care.
(OEI; 09-06-00430; expected issue date: FY 2009; work in progress)"

Outpatient physical therapists with high, unexplained utilization rates will have to show good documentation for their charges.

Physician-owned physical therapists will also have to demonstrate the following:

• Medical necessity for physical therapy (treatable findings)
• Expectation of significant improvement in a reasonable time frame (progress)
• Skilled physical therapy (PT decisions or PTA clinical judgment)

For a step-by-step program that a PT manager can implement without becoming a 'Medicare expert' go to BulletproofPT.com to protect yourself and to sleep well.

How to use the International Classification of Function

The value of any model is the ease with which people can adapt the model to their own ends and needs.

The International Classification of Functioning is a simple, powerful model that serves the needs of many stakeholders.

Physical therapist can use the ICF Browser to classify and diagnose their patients.

Physical therapy educators can use the ICF framework to train PT students to treat and measure function.

Researchers can use the ICF framework to measure outcomes of physical therapy interventions.

Government policymakers can use the ICF codes to collect, understand and manipulate data on the consequences of health conditions.

Professional societies, such as the APTA, can use the ICF to more accurately align their role in the health care system.

Non-governmental organizations, like the World Health Organization, can use the ICF to guide disability management.

Finally, for my purposes, the ICF is a tool that I can use to to help my physical therapists and physical therapist assistant staff write Bulletproof Notes for Medicare compliance in my outpatient physical therapy clinic.

What Alternatives for Physical Therapy?

The Outpatient Therapy Payment Alternative Project Synopsis is at the point of data collection...

"In order to collect the needed data, the project involves (1) the development of a data collection strategy, including the recruitment of therapy providers to participate in data collection..."

The Project needs to collect data on how to measure the patients you see in physical therapy every day.

Medicare would like to know three things

1. How disabled are they?
2. How much will they improve with physical therapy?
3. How disabled will they be at discharge?

"The Medicare Payment Advisory Committee (MedPAC), the Government Accountability Office (GAO), and outpatient therapy stakeholder organizations have suggested that the claims and administrative data currently available to CMS are not sufficient as the basis for developing better alternatives to the therapy caps."

Right now, the data collection instrument looks like it will be the Activity Measure for Post Acute Care (AM-PAC).

"the AM-PAC was designed to be used across patient diagnoses,
conditions and settings where post acute care is being provided"

.
I currently use the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) and I like it.
This project may dovetail with other projects ongoing at Medicare.

The Physician Quality Reporting Initiative (PQRI), affectionately known as Pay for Performance (P4P)may become a part of the Alternative Payment Model.

The American Physical Therapy Association (APTA) is working on a payment model (an alternative to the 'Alternative') that will pay providers more when the patient gets better in less than the expected number of visits.

"Value Purchasing in Outpatient Physical Therapy" by Alphonse Amato, PT, MBA in 2006 laid out a similar-sounding plan.

Go read it.

It sounds like a blueprint for the future.

Depends on who gets their way.

'Educated' Physical Therapist Sells Out Profession

I'm posting the most interesting parts of a conversation between Larry Benz, PT at MyPhysicalTherapySpace.com and Tim Richardson, PT of PhysicalTherapyDiagnosis.com about so-called 'below cost' reimbursement rates.

The first installment is Larry's link (above), to which I have responded on his blog.

His reply is next...

From the original post on MyPhysicalTherapySpace.com Larry writes the following...

"Tim:

Just trying to understand your perspective on the economics of this (physical therapy clinics accepting low reimbursement rates).

Agree with you on value.

It is impossible to do any delivery irrespective of financial viability.

Cannot understand how taking contracts below Medicare rates is fiscally responsible.

It is that type of financial naiveté that has led PT's to take rates at $40 per visit enacting the never ending limbo negotiations that occur ("how low can you go")."

To which I responded:

Larry,

I guess it depends on your size.

A small practice PT has better things to do with his time than treat patients for $40/visit (play with kids, fish, sleep).

A large PT practice with large fixed costs has to keep the dollars rolling in.

Any amount over your variable cost per visit is profit.

It's the same model the airlines use.

Ask you seat partner next time you fly...

"How much did you pay for your seat?"

If his is less than yours - why?

If yours is less than his - why?

The variable cost to transport one additional passenger is the cost of a bag of peanuts.

The rest is profit.

Same with PT.

Read this article. I use PT specific examples with graphs and charts.

'Stay Small and Make Big Profits' (August 2007 PT Products Online)

Tim

Physical Therapy is not a 'Loss Leader'!

Some physical therapists think that refusing to accept 'loss leader' patients from Medicare Advantage plans will preserve physical therapists' pricing power.

A loss leader (in retail) is a product that is priced less than it's cost to produce. For example, Office Depot might advertise reams of copy paper at $30.99 for a case for a catalog order but the Office Depot web site has that same case for $44.99.

Office Depot will take an up-front loss in order to get you to use their catalog. They are counting on higher order volume (more items) with each catalog order.

The catalog represents a fixed-cost investment that Office Depot must amortize through higher order volume. The Office Depot web site is a relatively low-cost distribution channel that can be profitable on lower sales volumes.

What has this example got to do with physical therapy private practices?

Physical therapy private practices are fixed-cost investments for their owners. The owners only get paid back on these investments when revenues exceed costs.

Once your fixed costs (such as rent, salaries and utilities) are met you must still pay variable costs.

The variable cost to treat the Medicare Advantage patient is the cost of the ultrasound jelly you smoosh on her neck.

That's not very much.

Medicare Advantage rates are (still) higher than the one smoosh of ultrasound jelly.

You make more money than you lose when your reimbursement rates exceed your variable costs of keeping your doors open.

Cash is King

Physical therapy practice owners with full-time employees realize that pay day comes every two weeks whether or not cash is in the bank or not.

High-volume Medicare Advantage patients on your caseload prevents your employee physical therapists from sitting idle.

Yes, Medicare Advantage pays less than Medicare.

Yes, you will lower your profit margin (but you will survive).

Yes, you may ask your physical therapist employees to see more than one patient per hour.

No, you may not use aides to treat your patients (any patients - not just Medicare patients).

How, you may ask, should a struggling PT private practice owner survive?

My recommendation...?

Find out why your patient hurts.

Make the physical therapy diagnosis.

Treat the cause of their pain.

Treat the actual change in 'body structure and function' that has lead to their painful, dysfunctional state.

Tell them why they hurt and why they can't lift things up and why they can't walk more than a city block.

You must have the skills and the ability to measure deviations from normal that qualify your patient for physical therapy.

The growth in physical therapy over the last 30 years is a real trend that reflects real demand.

The value of physical therapy is undeniable.

The cost of physical therapy, however, is climbing and is subject to policy and political whims.

Physical therapy will not go away with changes in Medicare reimbursement rates.

Your physical therapy practice may go away, though.

Change is inevitable.

What will you do to create the future for you, your patients and your country?

To learn how to measure, diagnose and treat your patients better get this free tutorial.

Physical therapists take note of Medicare audit process

The MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) Program: An Evaluation of the 3-Year Demonstration June 2008
report is available here (downloadable PDF).

Interpretations differ but most call the program a success citing the high amount recovered and the low amount recovered on appeal.

The Recovery Audit Contractors have recovered more than one billion dollars.

Amounts overturned on appeal were low...

"As of March 27, 2008, providers had chosen to
appeal 14.0 percent of the RAC determinations.
Of all the RAC overpayment determinations, only
4.6 percent were overturned on appeal."

Overpayments by provider type showed that physicians (which include outpatient physical therapists) accounted for only 2.5% of the total overpayments collected.

While some feel that the RAC program is on a 'bounty hunt' the results of this report that, not only are RACs here to stay but that soon they will be in all 50 states.

Physical Therapy Technology

Physical Therapy Diagnosis blog uses technology such as blogs, YouTube videos, Google AdWords and AdSense and Web 2.0 in general to drive home the message that Physical Therapy Diagnosis is simple and easy.

Every Physical Therapist should perform Physical Therapy Diagnosis using skills learned in our entry-level program (BS, MS or DPT).

One physical therapist, Mark Schwall, uses technology in general to improve our lives and our businesses at his website at Tech4PT.com .

In Mark's words...

"TECH4PT.com is dedicated to informing and educating Physical Therapists and anybody else with an interest in utilization of technology to improve their personal lives, business productivity and the visibility of their practices through leveraging the power of availability of technology and the Internet ."

Technology is not usually found in physical therapy education curricula. Technology is also usually not in the skill set of the physical therapist - just look at the low acceptance of 'paperless' or electronic medical records in small outpatient physical therapist offices.

I congratulate Mark on his new website.

I also challenge Mark to find meaningful and useful ways to help physical therapists improve our patients lives through the power and the wonder of technology.

Is Your Physical Therapy Valuable?

Is Your Physical Therapy Valuable?

Medicare only wants to pay for physical therapy that prevents a decline in function and subsequent loss of independent living.

For example, physical therapy that keeps a Medicare beneficiary at home and prevents a transfer to a nursing home is valuable to Medicare because the level of care and skilled services in a nursing home creates higher costs for the Medicare system and for society in general. Valuable physical therapy can prevent this loss of independence

Medicare wants to pay for valuable physical therapy.

Medicare will buy as much valuable physical therapy as you are selling.

Physical Therapy is a “Black Hole”

Physical therapist Alfonso Amato says in IMPACT magazine (Vol.3, Issue 10) the following:

“…payors describe outpatient rehabilitation as a ‘black hole’: they don’t know what they are paying for, don’t know the benefit of the service, and don’t know when the patient has reached maximum benefit”

Currently, the measure of the value of your therapy is the detailed chart documentation that describes the change in functional limitations and the change in physical impairments.

Chart documentation is what auditors look at to determine if you should return your fee, or not.

Medicare does not want to pay for physical therapy that is not valuable.

Is your physical therapy valuable?

Your chart documentation will tell you.

Audit Yourself

Can you open your chart, read your note and determine from one or two entries why and what the patient is doing in physical therapy? Is the patient improving functional abilities? Are their impairments getting better?

Does each entry reflect the skill of a physical therapist or physical therapist assistant? Is the skilled service obvious?

Show the Medicare auditor that your chart is full of hard data, critical thinking assessments, skilled physical therapy examples and diagnosis-driven decisions.

Write them down.

For example, use the language from the Benefits Policy Manual (Transmittal 63) to describe improvements in functional abilities:

“Objective data that demonstrates improved functional abilities is the OPTIMAL score decreased from 2.5 to 1.5 in 4 weeks, as expected”

Put that statement in your discharge note.

Make it easy for the Medicare auditor to decide to move on to the next chart.

Low-hanging Fruit

Don’t be the ‘low-hanging fruit’ that the auditors love to pick on.

Make your chart documentation difficult to disprove.

Make the auditor work hard to find a fault in your critical thinking.

Build a strong case for the physical therapy that your patient needs.

Argue for the patient, in writing, with numbers, measurements and functional scores that demonstrate the following:

* Skilled physical therapy services each and every session.
* Medical necessity for physical therapy services (only needs to be noted in the plan of care).
* Expect significant improvement in a predictable timeframe.

Imagine the following scenario:

You are an auditor paid to find fault with physical therapy charts. You find that most physical therapy entries are handwritten, overly brief and directed towards patient symptoms and specific tasks, like exercise.

Your income is based on finding charts that do not demonstrate the above criteria.

Yours is a thankless job.

Now you’ve come across a chart that is full of detailed impairment measurements, functional scores and sharp assessments that show critical thinking by the physical therapist.

The Treatment Encounter Notes are mainly numbers that show bilateral measurements and are compared against initial values. Goals are referenced weekly. Interventions are described daily.

Progress Notes are sent every calendar month for re-certification of the Plan of Care and include statements of medical necessity and justify any exceptions to Medicare caps on spending.

Discharge Notes clearly state who got better, by how much and who did not get better. The medical necessity for the non-responders is clearly stated in each discharge note.

You realize this chart will be a lot of work.

You can quickly scan this chart for any obvious omissions but your chances of a significant recovery are better if you move on to a different chart (and a different therapist).

Who Knows Who

In some cases, Medicare physical therapy auditors are physical therapists. They know what good physical therapy looks like.

To minimize your chances of a significant, unfavorable post-payment audit you should try to provide the best physical therapy you possibly can provide.

Provide valuable physical therapy.

Write it down.

Valuable, written physical therapy will survive a Medicare audit.

Valuable physical therapy is better for your patients.

Simple Beginnings

SIMPLE begins with a diagnosis – a diagnosis of a sick practice.

I was more eager than I was experienced when, in 2006, I bought controlling interest of my physical therapy clinics (3 of them) from our founding partners (2 of them).

After closing the sale the three of us were sitting around a large wooden conference table having a pleasant chat when one of the founders made this comment:

‘Our charts would never stand up to a Medicare audit’.

I can recall the frantic desire to find and tear into pieces my check and all the closing documents that we had just signed.

From that moment on I dedicated myself to developing a system that could reliably train and motivate my seven physical therapists and physical therapist assistants to quickly and completely create a Medicare compliant plan of care, daily note and discharge.

Most importantly, the system had to be based on the patient’s needs so that the therapist was allowed to do what the therapist does best: care for the patient.

I wanted a system that allowed the PT and the PTA to work together, using the clinical decision-making of the PT and the clinical judgment of the PTA5. I also felt the system needed to be diagnosis-driven from the start. A physical therapy diagnosis, that is.

I want to be able to share this system with my peers who own or manage their physical therapy clinics and who might not have access to a sophisticated corporate compliance department.

What I hope to present here is a standard process of measurement, diagnosis, goal setting and selection of interventions that displays both a rigorous thought process and an intuitive understanding of Medicare (and of the common needs of all third party payers, both commercial and federal).

Finally, the system should to both the experienced clinician and to the new graduate.

Tim