Physical Therapy Diagnosis Redefined

In updating my Facebook page I've rewritten the mission statement for the Physical Therapy Diagnosis blog.

As my knowledge and commitment to my physical therapy patients and practice deepen and broaden through years of study so has my understanding of this blog: it's purpose and it's power to educate and inform go both ways.

Many thanks to those of you who have chosen to respond and comment to my posts - your voices have enlightened me.

Many thanks also to the readers (500 strong each week) who choose to read only - your surfing helps this blog rank well in physical therapy web searches.

Physical Therapy Diagnosis Redefined

Physical Therapy Diagnosis blog is a forum that speaks to the difficulty in doctor-level decision-making for physical therapists.

By 2020, the APTA Vision Statement calls for all physical therapists to be educated at the level of the doctor of physical therapy.

Physical Therapy Diagnosis blog does not assume that today's practicing physical therapists are making daily decisions of sufficient complexity and riskiness to qualify physical therapists for the title of doctor.

Therefore, the format, quality and tone of the content on this blog will be aimed at improving daily decision-making among physical therapists.

Together, let's help physical therapists improve the quality of their decision-making and assume the title of doctor.

Recently, I have been told that I do not have the credentials (eg: DPT,PhD, etc) to undertake such a mission.

That may be so. Please, say so in the comments if you like.

I have also been told that my content is valuable, spot-on and relevant in today's ever-changing health care market.

If you like the content please sign up for the free Bulletproof tutorial below.

If not, thanks for reading.

A better way to save money

This is not my idea but it's worth repeating.

I first read about physical therapists being the 'gatekeeper' for high-volume, high-cost conditions like Lower Back Pain at MyPhysicalTherapySpace.com so I thought I'd use this blog to relay the message.

Let's see if it gets any traction.

You can help also.

Comment on this blog to improve its page rank or send your own ideas to Washington DC. President Obama is looking for a few good ideas here.

The Status Quo

This image is from Better Ways to Pay for Healthcare by the Network for Regional Healthcare Improvement and the Robert Wood Johnson Foundation.

This image dichotomizes cost into performance risk and insurance risk.

Medical providers should only have to worry about performance risk.

'Fee for Service' is in yellow - this is the status quo and it is dominated by physicians - good luck getting any traction there.

A Better Way

The 'Episode of Care' is where I think physical therapists would be adept at saving money and improving outcomes.

Presently, the episode of care for all diagnoses is only loosely organized by family physicians and other 'gatekeepers'.

'John' (from MyPhysicalTherapySpace.com) recommends this:

"...President Obama should appoint physical therapists as the nation's designated 'babysitter' for patients with musculoskeletal conditions.

In other words, our only role is to shield patients from the black hole of useless (and likely harmful) medical spend(ing)."

The Episode of Care is therefore based entirely on the Medical Model - patients come to us primed with MRIs and X-rays that trumpet their pathology and deflate the restorative power of physical therapy.


Physical therapists could intervene early, using the ICF/biopsychosocial model rather than the medical model.

I make the case for physical therapists manging the care of a lady who can't kneel down in the March 23rd PTD.

The Last Word

The third alternative payment model, Condition Specific Capitation would likely be managed by a large health system or hospital that looked at overall costs.

Can physical therapy show cost reductions for common, high-cost musculoskeletal conditions over an episode-of-care when PTs, instead of physicians, make the initial decisions for patient triage?

If so, then can we take responsibility for ALL the performance risk?

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?