Taking Routine Blood Pressures in the Physical Therapy Clinic

Physical therapists should be taking routine blood pressures in the physical therapy clinic.

We have evidence that physical therapists don't routinely assess blood pressure from Jette and Jewell's April 2012 study in Physical Therapy Journal.

Only 11% of 2,544 physical therapists in all settings measured and followed-up with blood pressure. Every time your patient comes in you, or a member of your staff, should take and record their blood pressure.

The Centers' for Disease Control and Prevention (CDC) reported today that over one-half of American's have hypertension defined as

"...average systolic blood pressure (SBP) greater than 140 mmHg or an average diastolic blood pressure (DBP) greater than 90 mmHg, or currently using blood pressure (BP) lowering medication."

Over one-third of Americans with hypertension were unaware of their problem and 90% of them had a usual source of care - that is, they had a doctor.

According to the CDC report: Vital Signs: Awareness and Treatment of Uncontrolled Hypertension Among Adults — United States, 2003–2010

"Nearly 90% of U.S. adults with uncontrolled hypertension have a usual source of health care and insurance, representing a missed opportunity for hypertension control. 

Improved hypertension control will require an expanded effort and an increased focus on blood pressure from health-care systems, clinicians, and individuals."

This is a major opportunity for physical therapists to assume an increased role in the care of Americans.

Physical therapists can position themselves as primary care providers by providing increased blood pressure monitoring and referral. Primary care providers, physicians and otherwise, will be an important workforce component for hospital systems participating as Accountable Care Organizations (ACO) within the Medicare Shared Savings Program.

Finally, to prevent a Medicare Audit a physical therapist can document routine blood pressure measure before, during and after exercise can show Skilled Physical Therapy.

"Skilled Physical Therapy" means that your service normally wouldn't be provided by a lesser trained provider, such as a massage therapist or athletic trainer.

Physical therapists work on medically complex patients where safety is a key concern. We know that 7% to 12% of individuals experience an adverse response to exercise. Adverse response is defined as:

"...an exercise-induced change that worsens a risk factor (such as BP) beyond measurement error and expected day-to-day variation."

Physicians probably cannot detect these individuals reliably. Physical therapists could measure blood pressure changes during and after and on multiple sessions of exercise. Adverse changes could provide the physical therapist with cues that could indicate a change in the Plan of Care or referral.

Skilled Physical Therapy Tied to Medicare Improvement Standard

Many physical therapists still believe that Medicare will not pay for therapy that does not lead to a change in functional status.

This is NOT true.

The Medicare Improvement Standard...

"...has a particularly devastating effect on patients with chronic conditions such as

• Multiple Sclerosis
• Alzheimer's disease
• ALS
• Parkinson's disease
• paralysis."

According to the Center for Medicare Advocacy:

"People with chronic conditions and long-term illnesses are often denied Medicare coverage because their medical condition will not supposedly:

• Improve on functional status scores
• They need maintenance services only
• They have plateaued
• They are chronic and stable

These reasons are referred to as the Medicare "Improvement Standard."  

Medicare is often the only insurance for this population, so, unfortunately, Medicare coverage denials can result in the loss of necessary health care.

This short podcast (7:11) from the Center for Medicare Advocacy may help you understand some of the issues these patients face in trying to get their necessary healthcare.

Unfortunately, due the the complex nature of Medicare documentation many physical therapists must waste valuable time learning how to document "skilled physical therapy" rather than actually treating patients.

I have found that patients often encounter barriers from their own physical therapists who may be uncertain or afraid to append the -KX modifier when care beyond the $1,880 is clearly necessary.

If patient progress is slow, marked by significant setbacks or difficult to measure the physical therapist may refuse to continue treating the patient.

Even though the patients' Medicare benefit allows physical therapy for these conditions.

The physical therapists' reluctance is due to fear of a Medicare Audit.

The Center for Medicare Advocacy has pressed a class action lawsuit against Kathleen Sebelius that may force Medicare to acknowledge its illegal "Improvement Standard" so that physical therapists may gain some clarification on our documentation requirements.

Please share tips on how YOU document exceptions to the $1,880 physical therapy cap.

"Immense Benefits" of Maintenance Physical Therapy

Maintenance therapy is going the way of the dinosaur, the dodo bird and the compact disc...

New, judicial interpretations of the skilled physical therapy and skilled nursing Medicare benefit have found that "improvement" is not necessary for coverage by Medicare and that maintenance therapy may be appropriate for some patients.



I have been a physical therapist since 1992 and, for my entire career, I have had it drilled into my head that we are not allowed to do maintenance therapy on Medicare patients.

It turns out now that isn't true.

Judith Stein, Executive Director/Attorney of the Center for Medicare Advocacy (seen in the above video) says the "illegal" Medicare Improvement Standard is being challenged in a lawsuit filed January 18th, 2011.

The lawsuit, Jimmo vs. Sebelius, may provide relief to patients needing physical therapy services and to physical therapists who want to treat these people.

Listen to this audio webcast announcing the lawsuit against Secretary of Health and Human Services (HHS), Kathleen Sebelius and Medicare (CMS).

According to Stein...

"This is a real problem that is affecting real people every day... some of our plaintiffs have passed away... (waiting for changes to the Improvement Standard)...and are no longer with us."

What about Outpatient Therapy?

Unfortunately, many patients in outpatient physical therapy do not get denials from Medicare when they hit the $1,870 Medicare PT "cap". Therefore, we may not be included in the class action.

Physical therapists have been "educated" to stop physical therapy and discharge patients when we see a plateau and no further improvement.

We have been told these "facts" by our managers and administrators and by Medicare "experts" for at least 25 years, according to the Center for Medicare Advocacy.

Yet, the patients who plateau may be at the greatest risk of a functional decline when we discharge them from therapy.

As a physical therapist manager, I admit, I have told my staff some of these very same things.

We all have plenty of these stories. If you or one of your patients have an advocacy story you may be able to contribute to the lawsuit against Medicare.

Physical Therapist´s Payment Option # 1

Three new poposed payment options related to the Medicare Physician Fee Schedule were published in the June 25th Federal Register and are available for public comment until August 24th.

The immediate concern is the proposed Multiple Procedure Payment Reduction (MPPR) policy but there are additional concerns that deserve physical therapists´ attention. I´d like to review the alternative payment options:

• Option #1
• Option #2 and
• Option #3

...and make recommendations for or against. As always, your comments are welcome on this blog. Also, please use the link provided to make public comments on the proposed MPPR policy directly to your government.

Note that CMS is not specifically recommending these alternative payment policies, at this time.

Option #1: New Severity and Function codes

The Centers for Medicare Services (CMS) would require physical therapists to replace the -KX modifier with new HCPCS Level 2 codes at Evaluation and Progress Note intervals (30 days or 10 visits, whichever is less).

PT Test or Measure	Function Codes	Code Description
Impaired Step Down Test	GxxxU	Body Function/Body Structure impairment - current
Impaired Step Down Test	GxxxV	Body Function/Body Structure impairment - goal
Slow Stair Measure Test (9 steps)	GxxxW	Activity Limitation/Participation Restriction - current
Slow Stair Measure Test (9 steps)	GxxxX	Activity Limitation/Participation Restriction - goal
3 steps into home	GxxxY	Environmental Barrier - current
3 steps into home	GxxxZ	Environmental Barrier - goal

note: I have added the PT Tests and Measures to show how these codes might be supported by evidence-based data in the patient chart.

Two severity modifiers have been proposed. This first chart shows modifiers based on the ICF:

Severity Modifier	Descriptor
0-4%	None
5-24%	Mild
25-49%	Moderate
50-95%	Severe
96-100%	Complete

This second chart shows modifiers for impairments, limitations and/or barriers as simple percentages:

Severity Modifier
0%
1 to 19%
20 to 39%
40 to 59%
60 to79%
80 to 99%
100%

Benefit: The policymakers are using International Classification of Function (ICF) descriptors to link physical impairments to function in a way that can be analyzed through claims reporting.

This option explicitly defines patient progress by comparing current and expected (goal) function.

CMS believes this option will lead to a decreased reporting burden because the -KX modifier would not be need on each claim line for patients over or near the PT caps.  Instead, only the new severity and function codes would be reported at (re)evaluation and Progress Note intervals.

These codes would also provide more information for medical review - at this time medical review (Medicare Audit) is a highly variable process that imposes provider liability based on largely pen-and-paper scribbled, narrative notes.

Risk: Physical Therapists in Private Practice (PTPPS), hospitals outpatient departments (Part B) and other settings may not routinely assess firsthand patient environmental barriers, especially those in the patient´s home.

Also, the link between physical impairment (body structure and function) and functional limitations (Activity and Participation Limitations) is tenuous and poorly described in the PT literature.

If such a link does exist it is probably NOT the linear, staight line conceptualized by Nagi in 1965 or the ICFDH in 1981.


This new coding scheme seems to hold physical therapists accountable for a conceptualized framework that is popular to academics and policymakers but is often absent from clinical realities.

Time Frame: Six months to two years.

My Call: I like this option because it gives physical therapists the chance (for the first time) to send claims-level data to CMS about the quality of physical therapy. 

This option may protect physical therapists from the Medicare Auditors´ concept of "skilled physical therapy" as a reason to deny claims.

Is Skilled Maintenance Therapy for Safety the future of Physical Therapy?

You can be audited by Medicare for providing exercise therapy to a aged person whose legs are 'feeble and unstable'.

They need you.

You're getting them better.

But, your therapy is not 'skilled' and you can't get paid - is that fair?

Skilled Maintenance Therapy for Safety refers to a fairly specific clinical scenario: one wherein the specific techniques may not require ongoing performance and assessment by the physical therapist.

Routine strengthening exercises may not require ongoing performance and assessment by the PT.

Skilled Maintenance Therapy for Safety is new to the Florida Local Coverage Determination for Therapy and Rehabilitative Services. (2/12/2009)

Skilled Maintenance Therapy for Safety Clinical Scenario
(found in the Medicare Benefit Policy Manual, Chapter 15).

Example:

"Where there is an unhealed, unstable fracture, which requires regular exercise to maintain function until the fracture heals, the skills of a therapist would be needed to ensure that the fractured extremity is maintained in proper position and alignment during maintenance range of motion exercises."

A similar case could be made for the large rotator cuff tear under the care of a conservative orthopedic surgeon. A simple therapy protocol often looks like this:

• 1st 6 weeks - PROM only
• 7th-8th week - AAROM only, no shoulder strengthening
• 9th-11th week - AROM only, no shoulder strengthening
• 12th week - begin shoulder strengthening

Is this the future?

How could skilled maintenance therapy for safety ever be good for physical therapists?

In 2010, physical therapists are still bound by silly 'process measures' that mandate 'how' we provide 'skilled therapy':

• -kx modifier
• 8-minute rule
• CPT automatic code edits
• physician certification of the plan of care
• 90 day re-certifications
• discharge notes

These rules stifle creativity and innovation in the clinic. Most of the innovation in physical therapy today is happening in academics, not in the clinic.

Instead of these limited clinical examples consider a patient at risk for falling down - a high proportion of the geriatric population (prevalance: 27-30%).

How might we treat them? Three times per week for four weeks?

Or, intermittently, with no set discharge date?

Shouldn't we get paid to prevent falls, rather than treat the aftermath of the fall?

The Florida LCD (p.22) states the following would raise red flags for a Medicare audit if they were included in a Medicare plan of care.

"...repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking, such as that provided in support for feeble and unstable patients"

Get paid to think like doctors think

There now exists a definite body of literature in support of a 'quantitative approach' to assessing future falls risk.

Factors that predict falls are easily measured and interventions readily assigned. The exercises and functional techniques, after a brief training period, are not that difficult or strenuous. The specific exercises may be repetitive but the quantitative risk assessment (performed weekly) is skilled.

The 'skilled' component is the assessment of future falls risk. The exercises or neuromotor training may NOT be skilled after a short training period. These become repetitive in nature - maintenance.

It's like the dental model. Most of the time I see the hygenist for the cleaning, prophylaxis and exam - the dentist is called in for complex conditions.

I would also recommend the examination of the whole patient - the 'Regional Interdependence Model' - looking for risk factors for adverse events other than falls:

Dysfunction and/or presentation	Test
rotator cuff weakness	Sidelying ER Test
cervical instability	Supine DCF Endurance
untreated episodic vertigo of peripheral origin (BPPV)	history
stiff hip	Prone Hip IR (bubble inc.)
high risk populations like adolescent females playing volleyball and soccer	history
post-partum females with 1st episode LBP	history

Because physical therapists are not dentists we have to document our skilled services - so I designed a template to quantify and record the risk.

The template is available here - along with withering criticism and commentary by physical therapists on the front line of patient care - like you.

'Skilled' Physical Therapy still not settled

'Skilled' physical therapy has been buzzing about lately - if you were lucky enough to catch the Rothstein Debates at PT 2009 in Baltimore then you may already be aware of what I'm about to tell you.

A new report from Developing Outpatient Therapy Alternative (DOTPA) describes, in excruciating detail, the distribution of $4.3 billion dollars paid for Medicare outpatient therapy in 2007.

The report also shows who billed what, for who and where. Without getting into the gory details (I don't want to spoil the ending for you) there are some data here that may give us some insight into physical therapist 'skill'.

This first table shows claim lines while the second table shows payments. Note the columns to the right, labeled 'PTPP' and 'Physician' (POPTs).

click the image to enlarge

This second table shows very much the same pattern in payments.

click the image to enlarge

I'll break it down a little more by carving out the rows for 'Ultrasound', 'Electrical Stimulation' and 'Massage Therapy'.

	PTPP	Physician
Claim Lines
Ultrasound	7.6%	10.6%
Electric Stim	2.8%	9.4%
Massage	1.0%	4.7%
Payments
Ultrasound	2.4%	4.2%
Electric Stim	1.2%	6.5%
Massage	0.7%	4.2%

I wonder what it is about the Medicare patient that demands twice as much ultrasound therapy when seen by a physical therapist employed by a physician?

Do patient findings drive 4-6 times as much electrical stimulation in a POPTs clinic as in my clinic?

Why are physical therapists even billing for massage? Oops! Maybe it's not physical therapists...

With all due respect to my peers who work in physician's offices - the numbers don't lie.

I don't know if the difference comes down to skill, dollars or undefinable but the implications seem clear.

Greater passive modality usage and fewer 'hands on' procedures leaves less room for physical therapists to practice their skills.

Get the full report from Developing Outpatient Therapy Alternatives (DOTPA) and Research Triangle International (RTI) here (Utilization Report 2009).

Faith and Physical Therapy

Today is Sunday, the 11th of January and faith is on on my mind.

"Now faith is the substance of things hoped for, the evidence of things not seen."
Hebrews 11:1

My first job in 1992 had me working with Mike, a physical therapist who would pray with his patients.

At the time I had no religion training and I didn't know quite what to make of Mike's non-traditional efforts to care for his patients.

Mike didn't pray with every patient, just those that seemed receptive and who needed that extra bit of inspiration to keep going and get better.

In 1992 neither Mike nor I had much knowledge of Medicare payment policy and so he would bill the patient for his time spent in prayer.

Today, of course, I realize that since prayer doesn't meet the criteria for physical therapy skilled services it shouldn't be paid for by Medicare or any third-party payer.

I tell this story because in 2006, Medicare spent $3.06 billion dollars on outpatient physical therapy services with no evidence that the services were any more skilled than Mike's prayer.

Now, maybe we all need a bit more prayer. I certainly pray more now than I did in 1992.

But, when we are talking about evidence of skilled decisions, we need to provide evidence that physical therapists' decisions matter.

Otherwise, we are no better (and no worse) than...

• massage therapists
• athletic trainers
• personal trainers
• 'kinesiotherapists'

...we are just more expensive.

Current efforts to improve physical therapists' decision-making tools come from several sources...

1. The Physician Quality Reporting Initiative (PQRI) - a much lambasted project begun in July 2007 to measure performance among healthcare providers. The project is cuurently establishing a baseline of over 100 variables that will gauge the health and function of Americans on such measures as falls risk, medication usage, pain, incidence of diabetic foot, body mass index and more.


2. Developing Outpatient Therapy Payment Alternatives (DOTPA) - kicked off in September 2007 with data collection set to begin in May 2009 this project aims to reduce the impact on setting (eg: home health, outpatient clinic, hospital) as a driver of payment.

The DOTPA project plans to develop two pen-and-paper outcome measures based on ambulatory status (walking and non-walking). The universal use of these outcomes measures will enable an 'apples-to-apples' comparison of patient outcomes across various settings.


3. OPTIMAL scale is one of the current professional consensus, Medicare-recommended outcomes tools for outpatient physical therapy. OPTIMAL is a broad outcomes measure that will enable the aformentioned 'apples-to-apples' comparisons.
   
   OPTIMAL is meant to be paired with a condition/disease specific measure such as the Lower Extremity Functional Scale, the Neck or Back Disability Index, etc.
   
   Yes, that means you may need to administer two seperate outcome scales to each patient.
   
   Other professional consensus, Medicare-recommended outcome tools are the Activity Measure for Post Acute Care (AM-PAC) and the Focus on Therapeutic Outcomes (FOTO)


4. The American Physical Therapy Association (APTA) provides continuing education on Medical Necessity and Medicare payment policy on a regular and convenient schedule.
   
   An encyclopedic resource on documenting skilled physical therapy services is the APTA's Defensible Documentation for Patient/Client Management


5. The Diagnosis Dialogs that are attempting to find descriptors (or labels) for physical therapists to describe the results of our clinical examination and evaluation. The descriptors/lables would be...
   

   "standardized anatomical, physiological or functional terms that concisely describe the condition or syndrome of the human movement system."

6. Edward's decison-making model shows how physical therapists decisions (and diagnoses) are different, complementary and equally important with physicans' diagnoses.


7. Bulletproof Physical Therapy Notes and Charts is my own effort to improve written decision-making through what I call competency-based compliance, that is, the intersection of evidence-based practice with Medicare payment policy.
   
   I've been working on Bulletproof for about two years and I have a book due out Summer 2009.

I haven't seen Mike in 10 years and I don't normally pray with my patients. I'm glad, however, that he showed me his example of patient care.

He showed me that his care, by his prayer, could be distinguished from his skill.

Hopefully, all physical therapists have stories of our care that may not show up on paper. There may be no evidence.

"Faith proves to the mind, the reality of things that cannot be seen by the bodily eye."

But now, we have new tools that can show our skill. We can justify the next $3 billion dollars spent on outpatient physical therapy. We can have evidence of the things we see in physical therapy.

What are your stories?

Dororthy got kicked out of Physical Therapy today

Dorothy got kicked out of physical therapy today.

Dorothy is one of my patients.

She is almost 80-years old, still lives at home with her husband and tries to walk every day.

She lives year-round here in Florida in the same town she grew up in.

Dorothy has a condition, called degenerative spinal stenosis, that causes her back to hurt when she walks more than one city block.

Dorothy has been to my physical therapy clinic for treatment of her stenosis three times in 2008: January, May and now in October.

Each time she has come to see me we have been able to help her walk better and maintain her independence.

Only now she has used up her Medicare physical therapy benefit.

I say she got 'kicked out' because that's how I felt when I told Dorothy that Medicare would likely no longer pay for her care.

Sure, Dorothy had the option to pay cash but, at $100 per treatment session, that is not much of an option.

I felt like crap when I walked her to the door and gave her a hug and said goodbye.

She was much kinder to me than I was to myself.

Dorothy said she understood the situation and that she would do her exercises at home.

What will happen to Dorothy?

The reality is that that Dorothy will begin a functional decline without skilled physical therapy.

How do I know?

I measured it.

In January, May and October I took functional measurements of Dorothy with a Medicare-recommended tool called the OPTIMAL scale.

Each time Dorothy came to therapy we re-measured her performance on the scale. Each session of physical therapy showed improved performance on the OPTIMAL.

Each time Dorothy stopped physical therapy her performance declined. The treatment effect was not persistent.

Dorothy's muscles around her spine were too weak to support her aged bones and discs.

Dorothy stopped walking because walking hurt.

She couldn't clean her house because vacuuming hurt her back and her husband had to do it.

She had to depend on her husband more and more and soon his back began to hurt.

At one point, I had both Dorothy and her husband in therapy.

The husband soon got better but Dorothy noticed that she was unable to push herself at home sufficiently to exercise her muscles. Also, she didn't have the specialized equipment, like spinal traction and exercise equipment, that we had in therapy.

Because of her age and her aptitude she was not safe working out in a self-pay gym setting.

Even a personal trainer was not a safe option for Dorothy.

What will I do?

If Dorothy calls me again in 2008, asking for help, I will see her for an evaluation.

Physical therapy evaluations are not subject to the cap.

Technically, you should not even have to append the -kx modifier to a 97001 CPT code for a patient over the cap since you need to evaluate them first to see if they qualify for the automatic exceptions to the cap.

In your evaluation you should measure impairments in body structure and function as well as activity limitations.

Link the impairments to activity limitations with your physical therapy diagnosis.

I measure activity limitations with the OPTIMAL scale.

Dorothy's OPTIMAL scale was graphed for 2008.

Here is what the graph looked like and how it provided the justification for going over her annual $1,810 per beneficiary, 'Uniform Dollar Limitation' (cap).



If you need to learn about 'justification statements' or 'the exceptions process' or even 'medical necessity for physical therapy' you can get free information at Bulletproof Physical Therapy Charts.

Give your patients all the physical therapy they need.

Unless they're ready, don't kick them out.

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.

The Physical Therapy Value Proposition

I've received notice that my value proposition is not as clear and logical as I thought it was.

My thanks to Larry Benz, PT Selena Horner, PT and Mark Schwall, PT for commenting on several of my last posts.

I'll try again.

Physical therapists measure patients:

• ROM
• strength
• extremity girth
• difficulty with activities (OPTIMAL)
• Fear-Avoidance Beliefs
• isometric lumbar extension strength
• the list goes on...

The measurements and the interpretation of these measurements is all that separates physical therapists from other professions that do many of the same interventions we do:

• specialized exercise by personal trainers
• massage by massage therapists
• spinal manipulation by chiropractors and osteopaths
• ultrasound and electric stimulation by athletic trainers
• splint and orthotic fabrication by orthotists and occupational therapists

Going forward, my recommendation is that physical therapists hang their hats on simple physical therapy measurements as the value proposition to the consumer.

Consumers like value.

Consumers include the following:

• Patients
• Insurance companies
• Medicare
• Industrial work places
• Schools
• Military

The value created in the exchange between the patient and the physical therapist is information.

Simple measurements create information which is valuable.

I'll give one example...

You measure a weak external rotator muscle and advise the patient that overhead lifting or throwing sports are risky because the likelihood of impingement and eventual tear is increased.

You have created new information that did not exist prior to your exchange with the patient.

You have demonstrated the medical necessity for physical therapy.

You have demonstrated skilled physical therapy.

Physical therapists need to take more measurements of their patients in order to create additional value during the exchange.

Outcomes are one type of measurement. The OPTIMAL is an outcome measure.

But measurements are also predictive. Measurements taken during the evaluation help the physical therapist select interventions and set long term goals.

Measurements allow physical therapists to classify patients.

Measurements allow the physical therapist to make a physical therapy diagnosis and, ultimately, a prognosis.

Without measurement there is no value in physical therapy.

Is the Nintendo Wii Skilled Physical Therapy?

You can go buy the Nintendo Wii Gaming System from Circuit City for $249.99.

I haven't done this but I could buy the Nintendo Wii Gaming System and use it in my physical therapy clinic billing patients for Therapeutic Activities (97530) or Therapeutic Exercise (97110) all day long.

You could also buy the Wii Fit Balance Board from Circuit City for $89.99 and put that in your physical therapy clinic, too.

Apparently, many physical and occupational clinics have done just that.

"Herrin Hospital in southern Illinois, about 100 miles southeast of St. Louis, bought a Wii system for rehab patients late last year.

At Walter Reed Army Medical Center, the (Wii) therapy is well-suited to patients injured during combat in Iraq, said Lt. Col. Stephanie Daugherty, Walter Reed's chief of occupational therapy."

I live in a resort community on the west coast of Florida and many of my retired patients would love to come to me for rehabilitation focused around their tennis or golf lifestyles.

Some physical therapists have declared that Wii is inappropriate in the physical therapy clinic,. Larry Benz is a physical therapist with a large following who has posted on multiple occasions at MyPhysicalTherapySpace.com about his displeasure with the Wii.

My position on the Wii (and technology in physical therapy in general) is this: Does it help the patient?

If technology (including the Wii) is good for the patient then we should consider its use.

I have not ready Larry Benz' every post so maybe he has already brought this next point up.

Is Wii skilled therapy?

Every third-party payer requires physical therapy be skilled physical therapy. Most insurance contracts have a 'boilerplate' section that mentions this.

Only Medicare has police powers so we usually just talk about Medicare requiring evidence of skilled therapy in the daily Treatment Encounter Notes.

Transmittal 88 has a specific definition of skilled therapy, as follows:

"Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently. A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period." (page 25)

This next section is repetitive but bears on the Wii issue...

"Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by
providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services." (page 42)

What is missing from the Wii debate is the diagnosis.

What is the specific impairment, addressed by the Wii, that is addressed that when treated, will significantly improve patient function?

Also from Transmittal 88...

"A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant."(page 27)

To paraphrase Hippocrates, "First, a physical therapy diagnosis".

What is Skilled Physical Therapy?

What do you do?

What do you do better than anyone else?

What can you do better than an athletic trainer, a massage therapist or a kinesiotherapist?

Can you progress your patient to a new level of exercise intensity, frequency or duration? Can you back down the intensity, frequency or duration?

Can you assess some new finding or physical sign not in the initial plan of care?

Will the patient leave your care better off than when they arrived?

Was their outcome more certain?

Physical therapists are paid more than athletic trainers, massage therapists or kinesiotherapists precisely because we do bring a greater level of certainty to each patient encounter.

Physical therapists produce better outcomes because risky patients don’t get worse with exercise interventions.

Physical therapists are paid more than athletic trainers, massage therapists or kinesiotherapists because the physician can expect that patients would otherwise not be safe.

An example of a post-surgical total knee replacement will help to illustrate this point.

Even an athletic trainer is qualified to show the patient how to do leg lifts for a weak quadriceps muscle.

But what if the patient came to therapy with a swollen calf, red, tender skin and radiating pain into the groin? Would the athletic trainer recognize a blood clot? Would the massage therapist use a standardized scale like the Well’s score to quantify the risk, document the findings and call the doctor?

Quantify the risk using standardized scales so that terms like better, risky and more are not just superlative adverbs but can be used as measurements for goal setting.

An impairment goal of therapy would be to reduce a Well’s score from 2/9 to 0/9.

A Well’s score of ‘3’ is a high risk for a blood clot.

See also the Medicare Benefit Policy Manual Section 220.2.C (page 20) for a definition and examples of skilled therapy.

References: Journal of Family Practice Online, December 2007. Web Accessed 3/12/08

http://www.jfponline.com/Pages.asp?AID=5728&issue=December_2007&UID=