Chiropractors need help in writing treatment notes

A new report from the Office of the Inspector General (OIG) on chiropractic services furnished to Medicare patients shows that chiropractors have as much trouble, or more, than physicians or physical therapists in writing notes on their patient care that show: 

• medical necessity (need)
  
• progress 
  
• skill (decisions) 
  

"Medicare inappropriately paid $178 million for chiropractic claims in 2006 (from a total of $466 million in Medicare chiropractic claims) ...

• 88% of the reviewed claims had inappropriate payments for 'maintenance therapy'
• 26% for undocumented care
  
• 6% for miscoded care
  
• 20% of the claims had multiple errors
  
• 83 % of chiropractic claims failed to meet one or more of the documentation requirements."
  

The Comprehensive Error Rate Testing program Paid Claims Error Rate for chiropractors, PM&R physicians and physical therapists in private practice (PTPP) shows the following error rates for the last three years:

CERT Program Provider Error Rates	2006	2007	2008
PM&R Physicians	9.1%	7.6%	8.9%
Physical Therapists in Private Practice	11.3%	6.1%	7.0%
Chiropractors	16%	11%	10.5%

The provider type with the lowest Paid Claims Error Rate is in bold.

The Executive Director of the Wisconsin Chiropractic Association, Russ Leonard, has called the OIG Report 'discriminatory' because the Medicare definition of 'maintenance therapy' seems to prevent chiropractors from performing chiropractic adjustments "...to maintain or prevent deterioration of a chronic condition."

Since physical therapists are held to the same standard for maintenance therapy the chiropractors claim of discrimination seems unfounded.

The OIG has been no less kind to physicians performing physical therapy - in 2002, the OIG found that 91 percent of PT billed by physicians and allowed by Medicare did not meet Medicare guidelines which resulted in $136 million in improper payments.

Physical therapists aren't off the hook either - reports of individual physical therapists receiving inappropriate payments from Medicare in Texas and Florida have surfaced recently.

What can provider do to show need skill and progress?

When writing your notes, try to answer these questions:

1. Why are you treating this patient?
   
2. How much do you expect them to improve?
   
3. How long will it take?
   
4. How much will it cost?
   
5. What factors (eg: co-morbidities, compliance, family or social issues) may delay or prevent you from meeting these goals?
   

An excellent tool that can help you answer questions #1,#2 and #3 is a baseline self-report questionnaire.

For example, the Neck Disability Index (NDI), developed by a chiropractor, is a simple, cost-effective tool to show medical necessity and, applied over time,  progress.

A complete literature review on the NDI is available in the May 2009 Journal of the Orthopedic and Sports Physical Therapy Association.

Chiropractors treating Medicare patients may need to learn new techniques and gain new tools for developing a Medicare plan of care for rehabilitation.

One of the specific requirements from the OIG report is the development of a chiropractic treatment plan for each patient that...

• includes a recommended level of care
  
• specific treatment goals
  
• and objective measures to evaluate treatment effectiveness
  

The tools needed to measure treatment effectiveness exist, on the sidebar of this blog, and elsewhere.

For a free e-mail tutorial on writing Bulletproof treatment notes using free, public domain tools, like the NDI, sign up below.

X-prize for physical therapy: $10 million for autonomous practice

The X Prize foundation announced yesterday the creation of a $10 million prize for a "bold, measurable and scientific" proposal that "results in viable, creative and achievable health care system changes."

Physical Therapists Take Note

This is your skill set!

The winning proposal will "improve care within communities and proactively assist individuals in optimizing their health in a way that reduces overall costs."

How to measure health?

Health can be measured differently: some measures are better than others.

For instance, rate of post-surgical bony fusion would not properly reflect the primary desired outcome from an instrumented spinal fusion.

Believe it or not, a validated questionnaire like the Oswestry scale is superior to imaging findings in measuring a construct like 'health'.

Physical therapists are getting better at using these measures.

The Criteria

The X Prize Foundation sounds like it is committed to a measure of health that is amenable to physical therapy interventions, namely

"good health based on better outcomes and an individual’s active participation.".

Proposals have to impact the lives of 10,000 people and improves their lives (health) by 50%. The measures used must meet the following criteria:

"...metrics will need to be at the community/ population level and objective and easy to track using validated tools, where possible...

We will weight the measures to place functional improvement at equal stature with sick care."

The Team Approach
Winning the X-Prize won't be cheap or easy but it may be worthwhile - are there any PTs up to the challenge?

Does anybody want to speculate what this baby is going to look like?

The following industry and trade groups were represented at President Barack Obama's one-day White house forum of changing health care in America.

1. AARP
   
   
2. National Federation of Independent Business
   
   
3. National Federation of Independent Business
   
   
4. Service Employees International Union
   
   
5. American Medical Association
   
   
6. American Hospital Association
   
   
7. Pharmaceutical Research and Manufacturers of America
   
   
8. America's Health Insurance Plans
   

Where was physical therapy?

Where were the physical therapists?

75-year old man runs marathon with 'bone-on-bone' arthritis

Just this weekend I attended the Running Conference at the University of Florida Orthopedics and Sports Medicine Institute in Gainesville.

There, one of the presenters claimed to have helped his patient, a 75 year-old runner, continue marathon training and racing despite Grade IV 'bone-on-bone' knee arthritis with bi-annual injections of hyaluronic acid (chicken cartilage) into the knee joint space.

Irrespective of testosterone-laden "atta-boys!" or of wry head-shaking at old ages' folly I still want to know this:

How was it paid for?

75 year-olds generally have Medicare.

Medicare usually pays for one course (3 or 5 injections) of viscosupplementation every six months in Florida.

Hyaluronic Acid (aka viscosupplementation) pays fairly well for the course of treatment: ~$250 for specialist surgeons and ~$150 for non-specialist physicians.

I, as a physical therapist, have to show that my 75 year-old patients need physical therapy to prevent progressive disablement, loss of independence or institutionalization.

For example, I can't say that one of my patient's goals is to...

1. Run a Marathon!

Marathon running is not "functional".

That is, racing marathons wont necessarily keep grandpa out of the old folks home.

Why (apparently) does Medicare pay orthopedic and sports medicine doctors to keep 75 year-olds running marathons when Medicare wont pay physical therapists to keep 75 year-olds running marathons.

Is there some evidence that chicken cartilage is more cost effective than physical therapy?

Spend Money on Health Care to Stimulate Demand

Physical therapists face a 15.1% pay cut in 2010.

Congress can prevent these cuts by voting to prevent an update to the much-hated Sustainable Growth Rate (SGR) portion of the physicians' fee schedule.

Why should Congress act on behalf of physical therapists?

Self-interest, to put it bluntly.

Congressional and American self-interest.

Physical therapy jobs are an important part of the United States economy.

Health care jobs are reponsible for half the job growth in the US economy since 2001.

"The good news is that if the housing market falls into a deep swoon,
health care could provide enough new jobs to prevent a wider recession."

But, the flip side of this upward trend is the larger trend of excessive US borrowing:

"...one explanation for the huge U.S. trade deficit is that the country is borrowing from overseas to fund creation of health-care jobs."

Uh oh, Congress is between a rock and a hard place!

What, you ask, will Congress do?

Well, your crystal ball is as good as mine is.

But, today's Online News Hour with Jim Lehrer spoke truth to power when, in the face of massive US job layoffs, the show's moderators advocate spending in order to 'elevate demand in the economy'.

Right now, the 2 trillion dollar US health care economy is 50% funded by the US government.

One specific reccomendation of the moderators...

• Spending money now on Electronic Medical Records (EMR) - expected 10-year return (according to Congressional Budget Office)= $90 billion.

Another spending item that will no doubt surface in discussions is the The Medicare Access to Rehabilitation Services Act (H.R.43/S.46) sponsored by the following:

• Congressmen Xavier Becerra (D-CA)
  
• Mike Ross (D-AR)
  
• Roy Blunt (R-MO)
  
• Senator John Ensign (R-NV)

In 2009, the therapy cap is an easy target that physical therapists need to popularize for the benefit of our patients.

It may seem opportunistic to exploit political circumstances for economic gain now but physical therapists must remember that, for too long, the policy-makers in Washington have exploited physical therapy patients and providers for such morally ambiguous concepts like 'budget neutrality'.

Act now and contact your congresswoman (or man) and ask them to suport H.R. 43/S. 46 .

Can Physical Therapists Treat Pain?

When I attended the University of Florida one of my physical therapy professors gave me this advice:

“Treating pain is a moral decision that may not be your primary therapeutic focus – treat function, not pain.”

At the time I wondered what my professor meant – treating physical dysfunction as the cause of pain in a way that alleviated the pain itself. This was a technique that eluded me for several more years.

I graduated from my university in 1992 without the benefit of learning the International Classification of Impairment, Disability and Handicap model (ICIDH) from the World Health Organization (WHO) for decision-making.

The ICIDH was first published in 1980 but it was intended for coding and manipulating data (eg: treatment codes), not for treatment decisions.

In 2001, WHO updated the ICIDH framework and re-named it the International Classification of Functioning, Disability and Health (ICF).

In June 2008, the American Physical Therapy Association (APTA) endorsed the ICF model.

“The model acknowledges that every human being can experience some level of "disability" and views functioning and disability as an interaction between health, the environment, personal and social factors.”

The new ICF framework, in my opinion and the opinion of others, greatly improves physical therapists’ ability to make treatment-planning decisions in the clinical setting.

“In clinical settings ICF is used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement.”

Making correct decisions as to the choice of treatment intervention at the initial evaluation will speed the acquisition of good patient handling skills and, ultimately, the collection of good data.

The evidence for function

Physical therapists consistently demonstrate an ability to improve function, reduce costs and healthcare utilization and generate satisfied patients. Physical therapists achieve these outcomes by focusing treatments on measured functional deficits.

Note: The references are available in the Bibliography at www.BulletproofPT.com.

Jewell DV and Riddle DL examined 1,804 patients diagnosed with sciatica and their response to physical therapy. Twenty-six (26%) of the patients (n=473) had a meaningful response on a follow-up questionnaire.

Patients who received joint mobility interventions and exercise were more likely to improve on the follow-up questionnaire than patients who received ‘spasm reduction’ interventions. Spasm reduction interventions included ultrasound, electric stimulation, heat and ice.

Another study, this one by Deyle GA et al reported on two groups of patients with knee osteoarthritis – one group received ‘manual physical therapy and exercise’ while the other group received de-tuned ultrasound. Eight weeks later, the treatment group receiving manual physical therapy and exercise improved 55.8% on the outcome questionnaire and 13.1% in distance in a six-minute walk. The control group that received de-tuned ultrasound showed no improvement.

A follow-up study by Deyle GA et al showed the effectiveness of skilled physical therapy over a home exercise program in 134 patients. By eight weeks the clinic treatment group had improved 52% while the home exercise group improved only 26%.

Subjects in the clinic exercise group were less likely to be taking their medications and were more satisfied with the results of their rehabilitation.

Finally, Fritz et al showed in a sample of 471 patients with acute low back pain that ‘adherence to the recommendation for active care’ decreased physical therapy visits, lowered physical therapy charges and led to greater improvements in pain and disability. A one-year follow-up showed that patients receiving ‘adherent care’ were associated with lower prescription medication usage, fewer MRI scans and fewer epidural steroid injections.

The evidence for pain

One study, cited by Medicare in its Physicans’ Quality Reporting Initiative (PQRI) Summary of Quality Measure Reporting Provision for 2009, instructed physical therapists and other eligible providers to assess pain prior to the initiation of therapy.

The Summary states the following:

“Reducing the intensity of pain by just 25% has been shown to achieve a 50% improvement in functional status”. 

Treat pain and measure function

One wise therapist helped me understand that we can do both - treat pain and measure function.

Physical therapists too often feel compelled to treat pain with modalities and throw in exercise and functional training if there is any time or dollars left over.

Pain is an impairment – an impairment that can be measured.

Pain is, however, just one impairment of many impairments that can be measured using new tools available to physical therapists.

Available tools (both free and paid) include the following:

• OPTIMAL difficulty and confidence scale (free)

• AM-PAC mobility and activity scale (paid)

• ICF disability framework (free)

• APTA Interactive Guide to Physical Therapist Practice, With Catalog of Tests and Measures (paid)

• FOTO (paid)

Futhermore, according to the ICF, pain will affect patient activities and participation differently in different people.

For a Bulletproof Chart, both pain and function can and should be measured.

Treating pain by improving function and movement is one of the essential skill sets of the physical therapist.

The physical therapist, using skilled decisions and judgment, links the various measured elements using the physical therapists’ diagnosis.

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.

United States physical therapists not alone in health care crisis

Physicians, and possibly physical therapists judging from the 'sports medicine' reference, in Canada are innovating their way out of another Medicare mess.

Private businessmen in Canada have opened several private-pay clinics in Calgary that treat patients with services that Medicare does not provide.

"The new Calgary clinic, the company's second location, will offer an "elite program" of medical care for its members, including a full health assessment and a preventative health plan."

The clinics are opposed by the Friends of Medicare, a pro-consumer organization that calls the expensive, private arrangements 'queue jumping'.

A queue is a line that refers to the way Canadians (and British) ration their health care services.

Canada rations health care according to age. Older folks go to the back of the 'queue' while younger folks with jobs get treated first.

The United States rations health care by wealth.

Wealthier people get treated first. In some areas of the United States Medicare is the best and fastest third-party payer which means that younger people with jobs are frequently treated last.

Arguments against this answer to Canadian Medicare?

"It sucks," said Noreen Branagh. "I can't afford the $4,000, and there are no family doctors in Calgary."

Arguments for this answer to Canadian Medicare?

"Primary care is in a crisis. At least I've gotten up and done something about it." says Don Copeman, the Vancouver businessman who founded the clinic.

Physical Therapy Diagnosis: Label or Process?

The new International Classification of Functioning, Disability and Health (ICF) speaks to the central decision physical therapists make in clinical practice:

What is wrong with the patient?

The ICF model seems to avoid the use of descriptors, or labels, that can be used to describe conditions related to human movement.

Fine with me.

The ICF Browser has descriptors of the following:

• Body Functions
• Body Structures
• Activity and Participation
• Environmental Factors

...that affect human movement and function.

Using ICF, I could make a diagnosis on a patient with neck pain that would look something like this...

"Patient has difficulty Bending, Sitting and Pushing (all measured by OPTIMAL scale) due to the following:

1. Stiff upper cervical sidebending (C0-C2).


2. Weak deep cervical flexors (DCF) muscles (measured by flexor muscle endurance test).


3. Decreased cervical rotation ROM, bilateral.
   

...to be treated with the following...

1. Therapeutic Exercise (97110) for endurance of DCF muscles.
2. Manual therapy (97140) for ROM, PROM, massage.
3. Neuromuscular Reeducation (97112) to distinguish cervical sidebending from cervical rotation.
4. Therapeutic Activities (97530) for Pushing with a stabilized cervical spine."

The descriptors used in ICF all have to do with measured findings.

The descriptors for the above diagnosis are the following:

Body Function:

• Mobility of several joints (b7101)
• Endurance of isolated muscles (b7400)

Body Structure

• Ligaments and Fasciae of the Head and Neck (s7105)

Activities

• Bending (d4105)
• Sitting (d4103)
• Pushing (d4451)

Without inventing a nomenclature or supposing the existence of any mechanism or model the physical therapist is able to accurately identify the structure at fault, the proposed treatment and the effect on the patient.

I make this diagnosis about 5-6 times per week.

Most of my patients (60%) are Medicare beneficiaries with typical, routine presentations that require a typical, routine evaluation.

I don't try to 're-invent the wheel' for each new patient I see.

I do take measurements for each descriptor listed above.

I should be able to describe to anybody the patients I treat, the intervention I use and the outcomes I expect.

'Anybody' includes the following...

• the patient
• the physician
• my physical therapist and physical therapist assistant peers
• third party payers
• federal policymakers
• national and international health researchers
• rehabilitation professionals from related professions
• the man on the street (?)

If you still want to use physical therapy diagnostic labels you will have to answer Dr. Andrew Guccione's question...

"What concepts are necessary to structure clinical observations into a recognizable pattern that also suggests physical therapy intervention?"

Generally, I recommend the ICF model to any physical therapist who wants to do a good job of treating function.

Specifically, I recommend the ICF model to any private practice physical therapist who wants to generate Bulletproof Physical Therapy Notes and Charts for Medicare compliance purposes.

Physical Therapists in Florida included in the RAC Rollout

Physical therapists in Florida are in the first round of states receiving provider education beginning October 1, 2008 according to an article in the September 11 AHA News.

The Medicare RAC Program is designed to augment exiting Medicare audit capacity and, in the words of former CMS Administrator Mark McClellan, M.D., Ph.D...

“There are two parts to making certain that Medicare dollars go to their intended purposes,” said CMS Administrator Mark McClellan, M.D., Ph.D. “First, we need clear and straightforward rules to assure that fair payments are made for services to Medicare beneficiaries and second we need effective mechanisms in place to detect and respond to inappropriate billing. In conjunction with new steps to ensure Medicare’s billing rules are clear, this demonstration will let us test a new approach to ensure that payments made to providers are accurate.”

This RAC expansion map shows the states affected on October 11.

My experience in Medicare Part B outpatient physical therapy is that the RAC audits affected PT's in Florida very little..

We had less than $100 in post-pay audits in the four-year scope of the three-year demonstration project.

Overall, Physician Groups had about $19 million seized as part of the RAC demonstration project.

Most of the money came from inpatient hospitals.

Get the full RAC demonstration report here.

Physical therapists and doctors: Get ready to hand over more documentation

Much in the news lately is the Office of the Inspector General Investigation of the Comprehensive Error Rate Testing Program.

As I blogged on Sunday, August 24, 2008 you-know-what will run downhill on this one.

Here is the OIG report for your reading.

In summary the report states the following:

"We recommend that CMS:

• require the CERT contractor to review all available supplier documentation;
• establish a written policy to address the appropriate use of clinical inference;
• require the CERT contractor to review all medical records (including, but not limited to, physicians’ records) necessary to determine compliance with applicable requirements on medical necessity;
• document oral guidance that conflicts with written policies, such as guidance on the need for proof-of-delivery documentation in making medical review determinations;
• instruct its Medicare contractors to provide additional training to physicians that focuses on improving their medical record documentation to support ordered DME items; and
• require the CERT contractor to contact the beneficiaries named on high-risk claims, such as claims for power mobility devices, to help determine whether the beneficiaries received these items and the items were medically necessary."

I've highlighted in red the requirement that I believe will lead to tougher audit standards on physical therapists and physicians - already overburdened with declining reimbursements and rising costs.

Physical Therapists Watch out for auditors in U-haul trailers at your office!

Did you work all day treating patients?

Tired?

Ready to relax?

But wait, don't you have to update your Medicare compliance plan?

Remember the one sitting on the shelf? Or, the one you've been meaning to work on?

Well, take heart...

I've assembled some resources that will help get you started or further along to completion.

The first is this recent article...

Altering Medical Records: What Not To Do When Being Audited By Medicare : Physician Law

The article is published on the blog of attorney Todd Rodriguez, who specializes in Medicare fraud.

This next resource is a recent post from the Physical Therapy Manager (PT Manager) list-serve at Yahoo Groups. You may be required to join the group.

The list is moderated but most physical therapists, administrators and some medical doctors and chiropractors have managed to get on.

Look for Victoria Cavitt's post from July 30, 2008 (she is replying to Jim Hall, CPA) and she talks about 'U-haul trailers with copiers' - here is a sample...

"They show up at your practice with U-haul trucks that house their own
copiers and OIG agents serve you a subpoena to access ALL your medical
records.

Medicaid and OIG employees randomly pull patient charts off your shelf, copy
these charts in their U-haul trailers, and look for patterns of inaccurate
billing and insufficient documentation. They don't give you advance notice of their arrival..."

That post got my attention - I kept thinking about those U-haul trailer all day at work! And I have a great Medicare compliance plan that meets all of Victoria's criteria.

I got my plan from the source documents - I'll tell you where to get those in just a minute - but first you should take a look at the basis for any Medicare compliance plan.

The DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Inspector General Compliance Program for Individual and Small Group Physician Practices is the authorizing document for any small practice tying to 'do-it-yourself' when it comes to compliance.

"We believe that the development and issuance of this voluntary compliance program guidance for individual and small group physician practices will serve as a positive step towards assisting providers in preventing the submission of erroneous claims or engaging in unlawful conduct involving the Federal health care programs."

Finally, I have this OIG document, the Medicare Manuals, an many more physical therapy specific resources all available for download at BulletproofPT.com.

You can get a free compliance tutorial that gives you 13 tips and strategies to 'bulletproof' your physical therapy practice.

Don't let the U-hauls get you.

Get Bulletproof PT today.

Developing Outpatient Therapy Alternatives

I just participated in an open-door session with the company that contracts with Medicare to develop a new way to pay physical therapists.

The firm, RTI International, has developed a web page called Developing Outpatient Therapy Alternatives that will have resources for clinicians to study an anticipation of the new measurement instruments.

On August 13th, the podcast of today's free, two-hour open door session will become available and I will post of provide a link here.

The new payment system is designed to prevent a re-occurrence of the Congressional/Executive S.N.A.F.U. on July 1 that I blogged about here, here and here.

Bottom line, the new payment system is seeking a way to 'risk adjust' patients so that Medicare can pay $50 for a simple ankle sprain and $2000 fro a complicated rotator cuff rehab. These numbers are make-believe but they make the point.

Consider for example two patients - each has the diagnosis 724.4 (Lower Back Pain). All Medicare has now is data from the claim form: that is the diagnosis 724.4 and the billed charge.

By the way, 724.4 is not a physical therapy diagnosis, it's just a CPT code that conveys little actual information.

Medicare would like information that helps them do the following:

1. Anticipate cost
2. Know how bad the patient is
3. Know how long the patient will be seen
4. Know how much better the patient will get

The new measurement instrument would most likely be a paper or web-based questionnaire that the patient and the clinician fill out together and update regularly, possibly as part of the Medicare Progress Note (every 30 calendar days or 10 treatment session - whichever is less).