An Open Letter to Florida Medicare (First Coast Service Options)

This author's continued investigation into the new Medicare policy of Skilled Maintenance Therapy for Safety will be published on this blog for your edification and comment.

The following letter was sent to medical.policy@fcso.com after the normal FCSO Medicare customer service reps were stymied by my questions.

Dear Medicare Policymakers,

The new (2/2/09) LCD for Therapy & Rehab Part B services (L29289) has new instructions for physical therapists (page 21):

Skilled MAINTENANCE THERAPY for Safety

"If the services required to maintain function involve the use of complex and sophisticated therapy procedures, the judgment and skill of a therapist may be necessary for the safe and effective delivery of such services.

When the patient’s safety is at risk, those reasonable and necessary services shall be covered even if the skills of a therapist are not ordinarily needed to carry out the activities preformed as part of the maintenance program."

However, the LCD goes on to clarify the clinical situation:

"It is not medically necessary for a therapist to perform or supervise maintenance programs that do not require
the professional skills of a therapist.

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

The most likely clinical scenario in outpatient physical therapy clinics is when the PT assess a patient likely to fall (complex and sophisticated services = skilled) on a patient whose exercises are necessarily low-level and repetitive (for feeble and unstable patients).

On the face of it, the new LCD language appears contradictory.

I wonder if you could provide some guidance?

Thank you.

Tim Richardson, PT

Merry Christmas from First Coast Service Options

Physical therapists have been given the 'gift' of maintenance therapy on some patients.

This 'gift' comes wrapped in bureaucratic gobbledeegook but is still an improvement over the dogmatic, no-way, no-how ban on maintenance therapy paid by Medicare that existed prior to February 2, 2009. (note: the FCSO primary geographic jurisdiction is only in the state of Florida)

Skilled Maintenance Therapy for Safety

The specific reference is located on pages 21-22 of the FCSO Local Coverage Determination.

I'll give you an example of the garbled way in which Medicare makes known it's intent:

"If the services required to maintain function involve the use of complex and sophisticated therapy procedures, the judgment and skill of a therapist may be necessary for the safe and effective delivery of such services.

When the patient’s safety is at risk, those reasonable and necessary services shall be covered even if the skills of a therapist are not ordinarily needed to carry out the activities preformed as part of the maintenance program."

The most obvious example in outpatient PT would have us treating patients at risk for, say, falling down in the home - even if the interventions might be construed as low level, 'unskilled' treatments.

However, the LCD goes on to say:

"It is not medically necessary for a therapist to perform or supervise maintenance programs that do not require the professional skills of a therapist.

These situations include: (among others)...repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking, such as that provided in support for feeble and unstable patients."

The LCD seems to contradict itself: If assessment of falls risk is "complex and sophisticated" then they are skilled.

If strengthening/confidence building exercises to prevent falls could be construed as maintenance, then these services seem to fit the new definition of 'Skilled Maintenance Therapy for Safety'.

It even seems appropriate to set goals for these 'feeble and unstable' patients such as 'No reported falls in 30 days' to measure the impact of our intervention.

Come to think of it, if I've assessed falls risk, constructed goals, designed an exercise plan of care and attempted to measure the impact then maybe I should just treat these people.

Does anybody else read this LCD the way I do?

Maybe next year I'll ask Santa for the gift of gobbledeegook.

Sugar, Fat and Physical Therapy

Can diet affect physical therapy outcomes?

Does the typical 'American diet' - high fat, high sugar - lead to the expression of anxiety-related behaviors?

University of South Florida researcher David Diamond, PhD recently found that a high carbohydrate/high fat diet caused 'avoidance behaviors' and anxiety among rats.

Dr. Diamond presented his findings at the Society of Neuroscience meeting in Chicago in November 2009.

Dr. Diamond concluded:

"This work indicates that the combination of high fat and sugar diets, as is found in typical American foods such as donuts, cheeseburgers and french fries, not only contributes to obesity, but may also contribute to the development of anxiety disorders."

He has also published studies on the link among high fat diets, chronic stress and the development of anxiety.

Now, I know you don't treat rats (not even the animal physical therapists!) but the effect of diet on mood and affect may have implications for physical therapy treatments - on humans.

I wonder if diet affects physical therapy outcomes?

Fear Avoidance Behaviors (FAB) may be the largest single, measurable factors leading to disability in people with musculoskeletal disorders seen in physical therapy clinics.

Fear-Avoidance Behaviors may explain why some people recover from their acute episode but never regain their full function and eventually go on to suffer recurrences of pain and disability - consuming greater and greater amounts of health services during their lives.

The 1987 Volvo Award in Clinical Medicine went went to Dr. Gordon Waddell of Scotland for his work in quantifying a test (Waddell's Signs) that proposed to assess 'illness behaviour' in orthopedic patients.

Dr. Waddell's 'illness behavior' was described in his award-winning study: A New Clinical Model for the Treatment of Low Back Pain.

'Illness behavior' morphed into the Fear-Avoidance Model that may explain from 15-30% of the variance in rehabilitative outcomes - the largest single factor physical therapists can modify in our patients.

Waddell's signs have since proved to be more 'common sense' than statistically predictive (Waddell's Signs have a positive Likelihood Ratio of 1.7).

Dr. Waddell, however, explained that:

...pathoanatomy does not correlate with pain and this is why we must take a functional approach.
The treatment goal is not pain relief but disability prevention.

The Fear-Avoidance Model improves physical therapists' diagnoses by shifting the emphasis during examination away from patho-anatomy and towards psychosocial stressors consistent with the Biopsychosocial Model.

Dr. Diamond's rats fed the 'American diet' exhibited 'stronger evidence of fear memories' and more fear on tests of memory and anxiety.

Physical therapists can modify or reduce Fear-Avoidance Behaviors by the use of:

"...effective brief psycho-educational strategies that can address the cognitive and affective processes that motivate pain-related activity avoidance."

Should we try to improve our patients' functional outcomes by providing advice on their diet?

RACs Get Complex

Up until now, Recovery Audit Contractors (RACs) have only been approved to issue demand letters for multiple, untimed codes:

• evaluation (97001)
• re-eval (97002)
• e-stim (G0283)
• traction (97012)
• etc

...per day per patient.

The RACs would review your billing profile using computerized, 'data drilling robots' that spot these un-listed Common Procedural Terminology (CPT) code edits and send you a demand letter.

The demand letter would arrive, automatically generated, with days, patients and dollar amounts listed.

Since multiple untimed codes are 'technical denials' there is no appeal.

Now, RACs are approved for complex review - that means they can request and review copies of your charts. They will attempt to find issues that would give basis for a medical necessity denial.

You can appeal medical necessity denials - and you should.

There is evidence that RACs inappropriately interpret published Medicare guidelines in making their denials.

For my state, Florida, Connolly Healthcare is the CMS-approved RAC. Connolly also administers the RAC program for Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.

For Physical Therapists: How NOT to think like a turkey

Do you want to avoid thinking like a turkey?

To NOT think like a turkey, first consider HOW turkey's think...

It's the day after Thanksgiving and a newly hatched turkey has arrived.

He has the coop to himself with plenty of room and no competition for food, etc.

Then, some humans arrive at feeding time. They provide food and water.

After that, they turn the lights down low, turn up the bed warmers and play some soft music.

"My," observes the turkey, "these humans must really love me - they must really be my friends!"

The turkey observes this same process for 364 more days.

Each day is an independent observation that seems to confirm the initial observation - that humans are friendly benefactors of turkeys and would never do anything to harm a turkey.

Then comes Thanksgiving Day and the humans arrive at feeding time - only instead of food they carry hatchets and axes.

"I wonder what those are for?" thinks the turkey.

Needless to say, the turkey dies with a very surprised look on his face.

The Outcome is Dinner

Now, what did the turkey do wrong?

How could the turkey have come to a different conclusion about humans presented with the same set of facts?

What could the turkey have done differently to change the outcome?

The Fallacy of Inductive Logic

The turkey committed the fallacy of inductive logic, first described in 1748 by David Hume, a Scottish philosopher, economist and historian.

Hume's contribution to empirical thought is an important cornerstone of the scientific method and to evidence-based medicine.

"Inductive inference is reasoning from the observed behaviour of objects to their behaviour when unobserved...it is a question of how things behave when they go (in Hume's words)...

"beyond the present testimony of the senses, and the records of our memory."

...we tend to believe that things behave in a regular manner; i.e., that patterns in the behaviour of objects will persist into the future..."

Hume's story uses chickens, not turkeys.

I have adapted Hume's story because turkeys resonate with Americans at this time of the year (Thanksgiving/Christmas).

Turkeys, chickens, David Hume and physical therapists are all searching for one universal constant - the TRUTH.

How can we find it?

For the physical therapist, TRUTH is the answer to these questions:

• What treatment will make my patient better?
• How long will the treatment take?
• How much better will my patient get?
• How much will the treatment cost?

In Hume's time the problem of induction was seen as a barrier to finding the truth. In other words, inductive reasoning (thinking like turkeys/chickens) did not seem to be the path to secular enlightenment (ie: the TRUTH).

Today, the foundation of the scientific method is hypothesis formation, usually by inductive reasoning.

The hypothetico-deductive model (thinking like physicians think) uses inductive reasoning to generate the initial hypothesis, and then to test the hypothesis:

1. Experience: What previous treatments have worked?


2. Why did the previous treatments work? What patient characteristics are unique to the responders (note: this example specifically describes Treatment Based Classification, or TBC).


3. Identify the patient characteristics (from the history or physical exam) that best predict which treatments worked (the outcome).


4. Test your theory.

What could the turkey have done different?

Find one human that likes to eat turkey. Then, the turkey could change his behavior to change the outcome (on Thanksgiving Day, run like hell).

In science, we question our assumptions - we test our theories and we learn from our failures. We're skeptics.

In physical therapy, we call this reflection.

Can PTs make BETTER decisions than physicians?

This International Classification on Functioning (ICF) video describes the unifying framework between the physician and the physical therapy frameworks by Gerold Stucki, MD at the University of Sydney in July 2009.

The link to the video can be found within the World Confederation on Physical Therapy (WCF) December newsletter.
Leaders in rehabilitation research aim to unify the Medical model (eg: pathology) with the Biopsychosocial model (eg: functioning).

The ICF is to be the unifying framework that provides a 'common understanding and dictionary of functioning'.

Imagine a physician asking you for the physical therapy diagnosis for a particular patient.

How would you respond?

What treatment recommendations would you make?

On what would you base your decisions?

What measurements justify your decisions?

Can you make decisions better than physicians?

The RAC Demand Letter No Physical Therapist EVER wants to get

Save yourself some time and money.

Take this sample RAC demand letter to your physical therapist in private practice (PTPP) office manager and let them know this is TOP PRIORITY - if you get a demand for return of overpayment you have 15 days to respond.



That's 15 days from the date in the upper left hand corner of the demand letter - not the date you find the letter in your mailbox. Here is the 4-page .pdf for download.

Why the rush?

According to Belinda Holmes, CPC/CCP of Kerkering/Barberio, an accounting and medical audit firm in Sarasota Florida, many demand letters wind up in the back office, on a 'to do' pile for several days before any action is taken.

Often, the person opening the mail is not even aware of the seriousness and potential financial liability of an automated RAC audit to a PTPP.

Offsets start on Day 41

Offsets are a 'bubble' in your Medicare cash flow pipeline. Offsets take money you would ordinarily collect in your bi-weekly Medicare check. The offset will continue until the entire amount of the overpayment is satisfied.

The demand letter has instructions for appeal - you should appeal since there is evidence that Medicare Recovery Audit Contractors are inappropriately interpreting Medicare guidelines.

Connolly Healthcare is the Florida RAC. They are only auditing automatic edits of PT un-timed codes in 2009,like...

• 97001 (PT evaluation),
• 97002 (PT re-evaluation),
• 971012 (Traction),
• etc (get the full list here).

In 2010 (almost here!), RACs may begin complex medical reviews of providers like PTPPs which means...

• requests for medical records,
• chart reviews and
• denials based on medical necessity,
• skilled physical therapy,
• insufficient documentation,
• no documentation,
• etc.

As I've said, the RACs currently only perform automatic edits on PT un-timed codes.

How to Use Fear Avoidance Beliefs in your Physical Therapy Plan of Care

We recently held a Treatment Based Classification Seminar (TBC) at our physical therapy clinic in Palmetto, Florida.

Most of the physical therapists attending (14) had a fairly good awareness of TBC but one item stood out - Fear Avoidance Beliefs (FAB).

None of the attending therapists used even the FAB 'clinical shortcut' in their evaluation:

“I should not do physical activities which (might) make my pain worse.”

The clinical shortcut identifies elevated fear-avoidance beliefs early, so you could treat them. A number of seminar participants expressed interest in how physical therapists could screen for and treat patients' Fear Avoidance Beliefs in their plan of care.

• What are Fear Avoidance Beliefs and Behaviors?
• What techniques should physical therapists use when these findings are present?
• How can we help these people or should they be referred to medical providers?

What are Fear Avoidance Beliefs?

Fear Avoidance Beliefs are one type of psychosocial factors that include:

• depression,
• anxiety and
• job dissatisfaction,

...among other factors.

Persons experiencing an episode of acute pain are believed to manage the episode by 'confronting' the pain or by 'avoiding' the pain.

Persons who exhibit these 'avoidance' beliefs and behaviors are significantly more likely to experience disablement as a result of their acute pain.

How to Use Fear-Avoidance Beliefs in the Plan of Care?

1. Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is a cool new tool that already fits the physical therapist skill set - although many of us may need additional training.

Some physical therapists may feel unprepared to render CBT but I would argue that the physical therapist is already well-suited to learn about CBT - it should complement our current 'toolbox'.

Cognitive behavioral therapy, within the context of our current practice, could be described as follows:

"Effective patient education by physical therapists appears to depend on the use of effective brief psycho-educational strategies that can address the cognitive and affective processes that motivate pain-related activity avoidance."

In other words, some of the same persuasive, coaxing, gentle, positive encouragement that most of us have used our entire careers to get patients more active.

Specific examples of some CBT techniques are as follows:

• keeping a diary of significant events and associated feelings, thoughts and behaviors;
• questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic;
• gradually facing activities which may have been avoided; and
• trying out new ways of behaving and reacting.
• Relaxation,
• mindfulness and
• distraction techniques are also commonly included.

George et al distinguished between the 'typical' educational approach of biomedical education and a fear-avoidance model of self-management.




2. Use FAB to screen for modalities

Childs et al found that use of electrotherapeutic or ultrasound modalities may encourage patients with elevated FAB to focus on their pain, avoid active 'confrontation' behaviors and lead to decreased outcomes.

Studies in America, Israel and the Netherlands tend to support the findings of poorer functional outcomes when modalities are used in the plan of care.

There is a significant chance that Medicare will decrease the relative value of modalities such as ultrasound or e-stim - even 'bundling' these modalities with other Common Procedural Terminology (CPT) codes, such as exercise, based on a lack of efficacy or effectiveness of modalities.


3. Predictor variable in TBC
   
   
   • Flynn's lumbar manipulation
   • Child's thoracic manipulation and
   • Hicks' lumbar stabilization rules
   
   ...all use the Fear Avoidance Beliefs Questionnaire as a predictor variable - lower levels of fear avoidance behavior generally predict successful outcomes. Hicks' stabilization rule is the exception - higher levels of fear-avoidance beliefs predicts success in this group.
   


4. Risk factor under a Medicare alternative payment system.
   
   Between 12-15% of the variation in the outcome of industrial workers' injuries was due to psychosocial factors, like FAB, not the physical or personal factors that physical therapists typically measure - like straight leg raise and Manual Muscle Testing (ugh).
   
   Since the payment by Medicare under an alternative payment system is likely to be a 'case rate' - say, $800 for 10 visits - anybody over the 10th visit is a financial risk to the provider.
   
   
   Physical therapists will need better measurement tools to identify these people, these outliers, early and perhaps apply for extra dollars.
   
   Screening for 'outliers' under an alternative payment system to Medicare Fee for Service will require sensitive tests to predict who is likely to need 20 visits for LBP, not 10 visits.

How can we cut costs and improve outcomes in physical therapy?

Since cost-cutting in healthcare is in the news recently I wanted to offer the physical therapist in private practice (PTPP) perspective - each cost-cutting measure is accompanied by a 'plus' (yes) or a 'slash' (no) according to whether or not I expect it to achieve its intended effect:


Health Information Technology (HIT)/Electronic Medical Records (EMR)

Most physical therapists will see a short run cost increase - don't be fooled by the price tag! Most of your costs will come in the form of time (if you are a small private practice) or altered workflows (everybody).

My experience with my EMR (which I am happy with) is a 3-4 month ramp-up time to build templates, change workflows, train workers and buy the accessory technology required.

Note that I am the primary physical therapist (with 2 PTAs) in a small (3,200 sq. ft.) office with three other employees. My face-time with the computer (not the patient) has increased with the EMR.

Nevertheless, the long run benefit of HIT is irrefutable. We all recognize the promise of computerization. Improved efficiencies, access to patient information and reduced provider burden (paperwork).

My EMR is a client-server model - I own the computer and I license the software for an annual maintenance fee. I paid $4,800 last year and I've done away with $300 in monthly dictation costs. Unfortunately, my dictation time went from 4 minutes to over 10 minutes. The accessory technology (server, PC-to-Fax, voice recognition software, etc) was another $7-8,000. Annual costs are probably less than $2,000 for maintenance and upgrades.

Unfortunately, there is no promise for improved outcomes for physical therapists since we don't prescribe medications and don't routinely read diagnostic imaging tests.

The APTA's position statement on HIT takes the prosaic view that we just need to 'hang in there' until physical therapists realize the benefits of improved technology but for now, the short run, computers and electronic records are just one more cost on your expense sheet.



Evidence Based Medicine (EBM)

EBM promises to improve patient centered outcomes, similar to improvements in acute pneumonia in community settings and acute chest pain in hospital ER's.

Pneumonia and acute chest pain were subjected to Clinical Decision Rules and Critical Pathways in the 1990s that mandated certain decisions at certain points based on certain criteria.

These high-cost, common conditions are amenable to 'quality improvements' by identifying the 'low-risk' patients that can be better managed at home or in outpatient centers. This allocates the system resources to better care for the high risk patients.

We don't have the studies yet to say that EBM lowers costs in physical therapy but several derivation studies have improved individual clinicians' decision making.

As with pneumonia and acute chest pain, several Treatment Based Classification (TBC) rules can identify patients who will NOT respond to physical therapy interventions and whose care is better managed with other techniques.

EBM may improve PT service volume if primary care doctors follow clinical prediction rules designed to identify low risk patients and order fewer expensive imaging tests.



Malpractice Reform

Physical therapists' malpractice costs are already already low (~$1,250 yearly for three providers in one 3200 sq. ft. office) - little promise for any improvements in PT practice expense.

Again, fewer primary care physicians ordering unecessary defensive diagnostic imaging tests may drive up volume for independent physical therapy practices. Better access to X-ray, MRI and CAT scans seems to drive up the rate of back surgery. A recent study in the journal Health Affairs shows that first time back pain patients get more surgeries in areas of above average MRI concentration.

The more important reform in medical malpractice reform might be the ability to renew a quality focus on 'systems errors' - the type that kill 100,000 patient annually - rather than on individual error.

This 2006 study from the New England Journal of Medicine found that 54% of the costs in malpractice settlements went to lawyers and administrative fees.

Few of these errors are the result of a single 'bad doctor' but on a fragmented system that is better at tracking procedure codes than individual patient outcomes.



Bundled Episode of Care Payments

Bundled payments are already saving costs and improving outcomes in a Medicare pilot project in five states. Lower infection rates and reduced hospital readmissions are the key outcomes measures in this project.

Many private practices feel that since the acute care hospital is the 'banker' the private practices may get the shaft.

The October 27th USA Today featured a story on the Medicare pilot program where one orthopedic surgeon was optimistic on it's success.

The surgeon named, Dr. Yogesh Mittal, received a 25% bonus for referring more patients to the hospital, which turned around and generated a 'slight profit' on 120 orthopedic knee and hip patients and 295 cardiac patients in 2009.

The physical therapy clinic named, Redbud Physical Therapy, does not participate in bundled episode of care payments since the program is only open to inpatient hospitals in 2009.

Redbud PT participates in the standard Medicare Fee for Service payment structure that is the mainstay of physician and therapy practices around the nation.

Jeff Jankowski, PT, ATC, Clinical Director & President of the Oklahoma Physical Therapy Association expressed some concern with bundled episode of care payments regarding the private practice PT clinic,

"I just don't think there's enough information yet", he said.

Jeff, I think you're right.

The International Classification of Functioning, Disability and Health (ICF)


The new ICF alters the way providers think about rehabilitation and disability. The ICF takes physical therapists away from the (dysfunctional) medical model and casts health in a framework centered on the person and what they can do and what they are able to do.

The ICF is not revolutionary - it's evolutionary.

The ICF was adopted in May 2001 by the World Health Organization (WHO) and the APTA in June 2008 as a framework for measuring health and disability at both individual and population levels.

The ICF shifts the focus away from the pathology and puts our attention on the person.

"By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability.

Furthermore ICF takes into account the social aspects of disability and does not see disability only as a 'medical' or 'biological' dysfunction."

Placing physical therapists into the role of the primary rehabilitative decision maker is an added responsibility but also an opportunity.

This new emphasis may encourage physical therapists to make decisions like doctors.

Developing Outpatient Therapy Payment Alternatives

The new Medicare 17-page PT evaluation form with 8 pages on 'Provider Information' that contains nary a validated test or evidence-based predictor rule puts the lie to the assertion that any new alternative payment system will cut costs or improve outcomes - at least in a way that is obvious to those of us outside of Research Triangle International's Technical Expert Panel (TEP).

Outcomes from another 17-page PT evaluation form are already being collected by the home health physical therapy Outcome and Assessment Information Set (OASIS) in the form of 'per cent improved'. The outcomes are ranked by state .

Any alternative outpatient PT payment system will likely be a case rate (eg: $800 for 12 visits) with extra dollars for 'risk adjusted cases' that show up as outliers (eg: 20 visits instead of 12). How physical therapists identify these outliers initially will be important.

Probable risk factors for therapy outliers include:

• age,
• psychosocial variables (fear, anxiety, depression)
• prior surgeries,
• disability scores, etc

Measuring these risk factors could be a sustainable competitive advantage for therapists competing against other providers like physicians and athletic trainers. The problem with the new Medicare PT eval form is that it doesn't seem to emphasize these factors.

The promise of the alternative payment system will be to cut long run Medicare costs and improve outcomes by moving away from a Fee-for-Service based payment system.

Unfortunately, a 17-page PT eval is going to feel time a short-run time cost to most of us.

Medicare Experts Recommend Physical Therapists Get a Comparative Billing Report

We've just completed the Classification Seminar with Special Guests Jim Needham, former CEO of a local physician owned physical therapy (POPTs) clinic and Belinda Holmes, healthcare auditor for accounting firm Kerkering Barberio on Saturday, November 7th.

Our audience of physical therapists and physical therapist assistants was very interested in Jim's talk:

"Competing with POPTs under Healthcare Reform"

We will have Jim's audio and PowerPoint available very soon. Also, Jim is being interviewed by Jeff Worrell on PT Talker this Friday the 13th.

Belinda had many good recommendations for physical therapists in private practice (PTPP) to build a Medicare compliance program in her talk:

"Medicare Defense Strategy: The RAC Attack"

The #1 question asked by our audience members after the seminar was on one topic raised by Belinda.

Belinda recommended that private practice owners get themselves a Comparative Billing Report from your local Medicare carrier - here in Florida your Medicare Part B carrier is First Coast Service Options.

You need to write a letter on your letterhead and request a specific six-month time frame for specific providers identified by National Provider Identifier (NPI) number.

Sorry, this option is not available for those providers billing as groups or 'incident to' the physician services (POPTs).

Here is the contact info for the Florida Medicare Part B carrier.

Statistical and Medical Data Analysis (phone: 904-791-8006)

First Coast Service Options
Statistical and Medical Data Analysis
P.O. Box 44288
Jacksonville, FL 32231-4288

There is no fee for providing these reports.

New seminar scheduled

Send in your application now for our next scheduled Classification Seminar on November 21st. You can apply here.

Private Practice Physical Therapists will get RAC data from Belinda Holmes

Belinda Holmes, BS, CPC, CCP-P will share her physical therapy RAC 'war stories' and tips to protect yourself from physical therapy automated claims review for 'untimed codes' in 2010.

Belinda will present

"Medicare Defense Strategies"

in Palmetto at Medical Arts Rehabilitation, Inc from 9am to 3pm - Belinda's part begins at 10:30am -11:30am on Saturday, November 7th, 2009.

Belinda works for Kerkering Barberio, a large Sarasota accounting firm with expertise in defending physical therapy clinic owners from Medicare audits.

Belinda is usually called in after the audit letter is received by the physical therapist and by then her job is usually 'damage control'.

At her seminar, Belinda would like to share with you ways to prevent that audit letter from ever reaching you.

Belinda's talk will focus on real-world, 'boots-on-the-ground' tactics you can use in your daily practice to prevent and defend your notes and charts from a Medicare audit.

1. RACs: What are they and how to avoid them
2. OIG 2010 Work Plan
3. Real life accounts of physical therapy audits
4. The new focus on medical necessity

Recent RAC missteps

RACs have not been putting up the kind of stellar numbers recently that earned their Demonstration Project permanent status in 2008.

The latest update of the three year Demonstration project in Florida, California and New York reveals that providers are right to have concerns about RAC improper application of Medicare guidelines.

Type of Reviewer	% of improper payment denials appealed by provider	% of appealed claims overturned in favor of provider	% of all improper payment denials overturned in favor of provider
Claims Processing Contractors	4%	59%	2.3%
Recovery Audit Contractors	22.5%	34%	7.6%

Since the percent of all 'improper payment denials' for RACs is almost three times the rate of MACs the data lend credence to the belief that RACs are not correctly interpreting Medicare guidelines.

Since RACs return overpayments successfully overturned at any level of the appeals process what can providers do to create a strong disincentive for RACs to incorrectly deny your claim?

Appeal!

Call 941.729.1800 to RSVP for Saturday's seminar.

You can get more information at www.BulletproofPT.com

Docs won't be able to own physical therapy, says Jim.

Physician Owned Physical Therapy (POPT) clinics may be on the way out in 2010 says Jim Needham, CEO.

Jim will present his seminar...

"Competing Against POPTs under Health Care Reform"

...in Palmetto, Florida on November 7th and 21st.

Jim Needman is a healthcare consultant and former POPTs CEO so he should know what he is talking about.

Jim's main premise is that physician practices will be unable to comply with new requirements in owning physical therapy clinics.

So you know a little bit more about Jim, here are some of his credits.

• Managed over 800 physicians across the United States
• Managed PT within several physician practices
• Most recently was the CEO of a 17 Orthopaedic and Pain Management practice
• 3 PT sites representing 20 therapists and assistants
• Worked for private practices and practice management corporations
• Closely monitoring ObamaCare and its effect on reimbursement and ancillary services ownership by physicians (includes; PT, MRI, ASCs, and others)

Jim says there is a 33% POPTs will be ruled illegal within three years - he bases his prediction on 'increased transparency and compliance requirements' large and small POPTs will have to meet under rules passed October 1, 2008.

The seminar is one hour - from 9am to 10am to be held in Palmetto, Florida at Medical Arts Rehabilitation, Inc. physical therapy clinic.

Immediately following Jim's presentation Belinda Holmes, CPA from Kerkering/Barberio will present

"Medicare Defense Strategy for Recovery Audit Contractors"

Some of Belinda's talk will include:

• RACs: What are they and how to avoid them
• OIG 2010 Work Plan
• Real life accounts of physical therapy audits
• The new focus on medical necessity

Finally, Tim Richardson will present four hours of Florida CEUs on

"Classification Decision Making for Medical Necessity and Skilled Physical Therapy"

Dates: Saturday November 7th OR Saturday November 21st

ConEd units: Four (4) hours CEUs from Florida FPTA.

Cost:

• $175 Early Bird discount (5 days prior to your selected date)
• $200 after the deadline or on-site registration.

Come to the seminar prepared to do the following:

• discover the role of POPTs in 2010
• lern how to protect yourself from RACs
• learn treatment based classification (TBC)
• practice new hands-on skills training
• apply evidence based techniques to physical therapy patient care
• improve your decision making
• make a physical therapy diagnosis

Call 941.729.1800 to ask for a course brochure or sign up by phone.

Credit cards, checks and cash accepted.

You can also sign up on-line at BulletproofPT.com and pay with PayPal.

If you want to succeed in private practice in 2010 you don't want to miss this seminar!

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?

Is Health Care Fraud Inflated?

Health care fraud costs Americans between $68 and $220 billion per year, according to a new report from the School of Public Health and Health Services at the George Washington University.

The large gap in the estimation of fraud costs exists, in my opinion, because of the imprecise definition of fraud. Black’s Law Dictionary defines fraud as...

“a knowing misrepresentation of the truth or concealment of a material fact to induce another to act to his or her detriment.”

Improper payment, the report goes on, is different from fraud. Improper payment is loosely defined as...

• errors in documentation
• errors in coding
• errors in reporting
• errors in verification
• ...and other technical matters related to administration

Fraud Exposed

The current administration and a new CBS segment on '60 minutes' claim that $60 billion in healthcare 'fraud' can be eliminated and that these savings can be used to pay for health care reform.

Unfortunately, most 'fraud' is not like that perpetrated by the barely literate 'Tony' in the new CBS video The $60 Billion Fraud (14 minutes) and it may not even be fraud - witness the $992.7 billion recovered under the Recovery Audit Contractors (RAC) Demonstration project from March 2005 to March 2008 in six states (New York, California, Florida initially and Massachusetts, South Carolina, and Arizona added summer 2007)

About 85% of the recovered overpayments came from inpatient hospitals ($828.3 million). Most of these overpayments fit the description of 'incorrect payments' - not fraud.

Inpatient hospital administrators are hardly the type featured by CBS in their inflammatory video. Incorrect payments arise the complexity of billing and coding rather than 'a knowing misrepresentation'.

The RAC Permanent audits are already showing, in their first year (2009), a 3x higher rate of overturned appeals than the standard Medicare audits. This implies that RACs are incorrectly interpreting Medicare regulations and denying too many claims.

Another implication is that the rate of incorrect payments (at least under RACs) is inflated.

Do academics and the media have an agenda?

I wonder if the media (like CBS) inflates the rate of healthcare fraud for its own purposes?

The George Washington report goes on to say that:

"...80% of healthcare fraud is committed by medical providers..."

Yet the same report lists the results of a legal search engine query from 2000-2009 based on the type of company: provider, insurer or pharmaceutical. The fraud was both public (Medicare) and private.

Humana Inc. is categorized with the insurers even though it is described as a 'major hospital corporation-affiliated private insurer'.

Industry	Recovery (millions)	Per Cent
Provider	$2,122.25	38.9%
Insurer	$890	16.3%
Pharmaceutical	$2,459.75	44.9%
data from Rosenbaum et al. Health Insurance Fraud: An Overview. June 2009; George Washington University, School of Public Health

It is worth noting that the Insurer group is made up of 4-5 major American companies (UnitedHealth Group, Humana, AmeriGroup, HealthNet, et al) and the Pharmaceutical group is made of just over 15 major, international companies (TAP, McKesson, Merck, Serono Group, Wyeth, AstraZeneca et al).

The Provider group, however, is made up of over 5,500 American hospitals, large and small, and innumerable private practices, group practices and billing entities with differing levels of compliance sophistication.

These data hardly support the "80% of health care fraud is from providers" assertion.

It also strains credulity to think that the $6 billion or so over the last 9 years could somehow morph into the expected $60 billion annual savings required to pay for health reform.

Three reasons why POPTs will give way to PTPP in 2010

Just this week three things have happened that lead me to question the survivability of the physician-owned physical therapy (POPT) model in 2010.

By the way, none of this seems to be directly affected by the direction of the health care reform debates - whichever way reform goes the POPT outcome seems destined to happen.

ONE

A Medicare Payment Advisory Commission (MedPAC) meeting October 8th listened to APTA testimony on physician ownership of physical therapy clinics. MedPAC addressed concerns about Medicare PT volume growth and ownership of PT.

Physicians who own services, like PT, to which they refer have a conflict of interests (their interests vs. their patients' best interests).

MedPAC outlined these concerns in a PowerPoint presentation by staffer Ariel Winter whose concerns are the following:

1. Could lead to higher overall volume through greater capacity and financial incentives.
   
   
2. Several studies find that physician self-referral is associated with higher volume.
   
   
3. Unclear whether additional services are appropriate or contribute to improved outcomes.

TWO

Jim Needham, former CEO of a Florida POPT, predicts a sell-off due to difficulty with compliance and transparency requirements especially small physician practices that employ physical therapists.

Jim does suggest that costs (the subject of the current debate) are the primary driver of new physician compliance legislation.

You can sign up to hear Jim's presentation in Palmetto, Florida on November 7th or November 21st at BulletproofPT.com.

THREE

My phone has been ringing off the hook from business brokers and 'principals' (guys and gals with money) who all of a sudden want to invest in outpatient physical therapy practices.

My phone rings because I sold two clinics in two separate transactions in the last two years so I'm on a list somewhere. Lucky me.

Do they know something we don't?

Maybe it's just a thaw in the frozen credit markets but physical therapy business sales are getting hot once more.

The other consideration is that investors perceive increased future expected cash flows to Physical Therapists in Private Practice (PTPP) and they see PTPPs selling for all-time historically low valuations and they want a bargain.

Maybe 2010 will be the year of the PTPP.

My advice to PTPP owners - hang tight, this may be your year.

Heads Up! Physical Therapists in Private Practice (PTPP)

The annual issuance of the Office of the Inspector General's (OIG) 2010 Work Plan sets the tempo for all subsequent Medicare audits - since the OIG is the agency that actually audits Medicare (CMS).

Here is what the Work Plan actually says about physical therapists in private practice:

"Outpatient Physical Therapy Services Provided by Independent Therapists

We will review outpatient physical therapy services provided by independent therapists to determine whether 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-00-10-35220; various reviews; expected issue date: FY 2010; new start)"
(page 29)

Physical therapists in Private practice should focus their attention on two areas to make sure that their compliance plan meets Medicare requirements:

Process Measures such as the following:

• 8-minute rule
  
  
• -kx modifiers and the arbitrary PT caps
  
  
• PT/PTA supervision requirements
  
  
• Medicare Minimal Documentation requirements
  
  
• ‘Skilled physical therapy’
  
  
• One-on-one procedure codes
  
  
• Untimed modality codes
  
  
• -59 modifiers and CPT code edits
  
  
• Physician certification of the physical therapy plan of care

Evidence-based physical therapists who truly care about their patients and about the job we do will also want to direct their attention to Outcome Measures such as the following:

• Patient self-report outcomes and questionnaires (eg: OPTIMAL, LEFS, etc.)
  
  
• Therapist-administered performance tests (eg: Gait Velocity, TUG Test, etc.)
  
  
• Impairment-level tests and measures (eg: SLR, neck rotation, etc.)

Finally, one self-administered process measure is Treatment Based Classification (TBC), which has the potential to...

• save costs,
  
  
• improve outcomes and
  
  
• elevate physical therapist decision making

TBC can show Medical Necessity and Skilled Therapy - two important areas of Medicare Minimal Documentation requirements.

To learn more about TBC and Medicare compliance you can attend one of the Classification Seminars in Palmetto, Florida on November 7th or 21st at the Medical Arts Rehabilitation physical therapy clinic from 9am to 4pm.

You can sign-up online at BulletproofPT.com

POPTs Leader Predicts Massive Sell-Off under Health Care Reform

The Senate Finance Committee, on Tuesday October 13th, just voted 14-9 to move the fifth and final version of healthcare reform out of committee and back to the Senate for merger with more generous versions of health reform legislation passed earlier this year.

The latest measure passed with a party line vote (Democrats outnumber Republicans 13-9 on the committee) - with Olympia Snowe (R-Maine) siding with Democrats.

In Bradenton, Florida former Physician Owned Physical Therapy (POPT) clinic leader Jim Needham, CEO (MBA) predicts ominous tidings for his former employers as a result of this legislation.

Some of Jim's key points:

Why there is "Momentum Against Physician Ownership in Ancillaries (Physical Therapy)"

1. "Significant trend data showing increased payment to physicians in relationship to physician ownership growth"


2. "Generally they get reimbursement rates based on their contracts which are greater than independent PTs can get"


3. Jim predicts a 33% chance that POPTs will be ruled illegal within three years

I don't want to spoil Jim's presentation but suffice to say that much of this information is rather volatile - most POPT physicians may not even be aware of the transparency and compliance implications that Healthcare Reform will bring to their practices!

We've "mashed-up" Jim's presentation with an existing seminar on November 7th or November 21st and we're hoping the two topics are complementary:

"Classification Decision Making for Medical Necessity and Skilled Physical Therapy"

with Special Guest former POPTs CEO

Jim Needham

"Competing With POPTs under Health Care Reform"

Jim will go into greater detail during his presentation in Palmetto on November 7t and 21st and you can sign up now at http://www.bulletproofpt.com/.

The online option lets you pay with PayPal.

You can also call 941.729.1800 to register over the phone.

Finally, you can print the webpage at http://www.bulletproofpt.com/ and mail in your application along with your check - don't wait because the Early Bird Discount expires 5-days before each course.

What will health care reform bring for American physical therapists in private practice (PTPP)?

Hard to say.

Some aspects are obviously positive, such as greater transparency in physician self-referral. Other aspects may not be so positive - such as a failure to reform the physician fee schedule and the (un)Sustainable Growth Rate (SGR).

For greater insight and success in 2010 come and see Jim's presentation.

What are your thoughts?

Sign up now for the course!

Don't forget to fill out and send in your application form.

Dates

Prior to November 2 $175.00Prior to November 16 $200.00

How to Sell Physical Therapy

How good are you at 'selling' your therapy?

Can you 'close' the deal?

Or, do you let the customer slip away?

If your customer slips away does another, better 'marketed' professional (MD ortho, DC, Pain doc, etc.) provide the care they need?

Maybe physical therapists should consider how we position ourselves when it comes time to 'close the sale' - according to Israeli researchers using American outcome tools:

"Compliance with self-exercise programs was one of the strongest predictors overall and the strongest predictor among process variables.

Better outcomes were achieved when patients were more compliant with their exercise program. This result has important implications for clinicians.

Ability to improve patient compliance is probably more of an educational skill than a clinical skill. One could perceive this as a marketing skill.

Physical therapists need to know how to educate and persuade patients that what they are “selling” actually works."

Daniel Deutscher and the folks at FOTO examined 22,019 people in 54 clinics in Israel over a two-and-a-half year period to see how the process of therapy affected the outcome of therapy. One of their findings was the association between exercise compliance and improvement.

If any non-physical therapists read this blog then that last statement could sound like a 'no-brainer' but physical therapist education does one thing very well - it makes believers out of physical therapists. We believe in the power of physical therapy to improve our patients lives.

Too bad physical therapy educational programs don't also provide training in 'selling' and 'marketing'. I'm thinking of calling up my alma mater and asking for my tuition money back!

The Israeli researchers are right - home exercise 'compliance' (I prefer collaboration) and adherence to scheduled visits separates the patient winners from the losers. Small setbacks can prevent patients from meeting their therapy goals- a painful flare up, arriving late due to traffic, the therapist changes the plan of care...

One telling example happened to me yesterday.

I employ physical therapist assistants - one of my PTA's asked a returning patient "How are you today?" the patient replied, "I'm sore from lifting at work" to which the PTA promptly said, "Well, let's put you on lumbar traction"...

• no neurological testing
• no leg signs
• no clinical rationale at all

...other than activity-induced lower back pain. The exercise program was aborted and traction was begun.

Why does the physical therapist culture encourage easy modality, massage and traction treatments when the accumulated evidence seems so heavily weighted against these interventions?

Why does it take a sample of 22,019 patients to show us the optimal treatments for persons with musculoskeletal injuries - when most physical therapists recognize the futility of modality therapy after six months on the job?

A 2005 study by Riddle and Jewell showed poorer outcomes associated with ultrasound and electrical stimulation therapy for sciatica patients.

Is there a way to break the physical therapy cultural modality mindset?

I think there is.

Make a culture of measurement.

Simple tools now exist that make measurement easy - easier than I had it in 1992 when I graduated with a Bachelors in Health Science, armed with Manual Muscle Testing to go forth and cure back pain and prevent folks from falling down.

No, physical therapy measurement tools are better now and we no longer have so many excuses for not knowing why the patient can't or won't get better.

Unfortunately, we are no longer in the driver's seat when it comes to determining our own fate or the fate of our patient's - government mandates are gobbling up therapy time with 17-page home health assessments and 30 minute outpatient therapy assessments - no time left for the patient.

I'm from the Government an I'm here to help

Government mandates are different from standardized assessments. Frequently, the government messes things up by trying to satisfy too many constituents.

We already have many good assessment tools:

1. Self Report measures
2. Performance measures
3. 'Old School' impairment measures
4. Classification measures

Fewer than 50% of physical therapists in the United States use outcome measures - that's like driving your car without a speedometer - with your eyes closed! No wonder modality treatments dominate therapists' thinking.

Sell the Outcome

We saved my traction lady.

She went back on exercise and functionally oriented training the next session, I gave her a follow-up questionnaire and she showed improvement over last week - traction did not help.

I asked her what she thought - she said she was sold on physical therapy.

Physical Therapy, Silver Coins and Green Eyeshades

We need a common coin of the realm.

After Napoleon's final defeat at the Battle of Waterloo on June 18, 1815 the British bond market rallied as investors predicted lower government borrowing for future wars. Nathan Rothschild arrived in London just hours ahead of the news of the battle's outcome and began buying up British war bonds at bargain basement prices.

Bond prices rose as yields fell and Rothschild sold at a huge profit. Rothschild's future was made in those months following Waterloo. Many sources credit Rothschild as the pre-eminent banker, speculator and, some say, the most powerful financier of the nineteenth century.

After securing his fortune Nathan Rothschild went on to become famous and also managed to create a standard that still affects our lives today. He demanded, and got, due to his money and influence, a uniform system for paying bond holders in sterling silver - no matter which country they were from. Investors no longer had to go to London to receive their bond coupon payments and sterling silver became the coin of the European investing realm.

Improvements in payments made bonds more attractive to investors and, ultimately, easier for Rothschild to sell. Bond holders were better off, governments gained access to new funding and Rothschild got richer.

I see a parallel here.

Couldn't physical therapists demand a uniform measurement system for rehabilitation outcomes? If all rehabilitation professionals had a common measurement system (eg: standardized performance, self-report, impairment or classification measures) then physical therapist outcomes could be compared with other rehab professionals. Right now, the only available comparisons are based on setting (eg: POPTS, PTPP, hospitals, etc.) and the only available measure is cost.

What if physical therapists could compete with physicians on outcomes?

Physician owned physical therapy clinics (POPTs) are slightly lower in annual Medicare, per beneficiary costs ($522) than their Physical Therapist in Private Practice (PTPP) peers ($871) but that may be due to the 'Flying Below the Radar' effect.

Unfortunately, cost is not the best measure of competitiveness. Not if you believe that quality service is a better measure. WalMart competes on cost - would you buy healthcare from WalMart?

Physical Therapists under Automated Review

Right now, in America, powerful computer algorithms are sifting your claims data and looking for patterns outside the 'bell curve' - do you do a lot of manual therapy?

Four manual therapy units (1 hour) per visit? You are outside the curve.

Automated reviews, conducted by Recovery Audit Contractors (men in green eyeshades), are looking for duplicate payments like two spinal tractions in one day. Spinal traction is a 'supervised modality' - you set it and go treat another patient. Totally legal - however you can't charge more than one per day per patient.

Recovery Audit Contractors (RACs) made some good money in Florida, California and New York from 2005 to 2008 during the RAC Demonstration Audit with automated reviews.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80/year	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

I posted this chart originally on June 8, 2009 from my own clinic data as well as US government published data from the RAC Demonstration Audit Report (June 2008)

I define 'good money' as the piddling amount RACs 'recovered' from me because cost/investment = $0 and return = $80. To the men in green eyeshades the calculated ROI is infinite.

Michael Apolski's Medicare Update blog is quoted in the September 2009 issue of Orthopaedic Practice Management - he discusses automated reviews on page 99.

"RACs can analyze claims using two methods. During “automated” review, they attempt to find “the low-hanging fruit” by making a claim determination at the system level without even reviewing the medical record, Apolskis says."

Alternative Physical Therapy Payments

The current lead contender for a 'common coin of the realm' is a tool being developed by a private-public partnership, Research Triangle Institute (RTI).

I have a couple of concerns with RTI's Developing Outpatient Therapy Payment Alternatives (DOTPA) project:

1. Despite their attempts at outreach they still have a government mandate - they can ram it down our throats, if they want to.
   
   
2. Their assessment tool is expected to take 15-30 minutes per patient! No time left for patient-therapist collaboration or establishing rapport.
   
   
3. Is RTI re-inventing the wheel? Physical therapists already know how to assess our patients - do we need a new setting-specific tool? Couldn't we do better with a set of condition-specific measures for common, high-volume conditions like the Oswesty for lower back pain or the SPADI for shoulder pain? Let the clinician choose.
   
   
4. How many physicians could manage the transition from profit-driven POPTs to outcomes-driven care? Would running a PT clinic under those circumstances (ie: when you're not a PT) be worth the 'hassle"?

Nathan Rothschild seized a singular moment in world history and used it to shape the future of finance - could physical therapists seize healthcare reform as a springboard to position evidence based physical therapy as the universal standard by which all rehabilitation professionals are judged?

Could we 'sell' physical therapy to a skeptical public of payers and government policymakers when we are all better off with outcomes?

An open letter to the American Physical Therapy Association

This letter was sent to a contact at the APTA on September 21, 2009.

This letter is intended to initiate a discussion and propose a course of action that is in the best interests of Medicare physical therapy beneficiaries, the American healthcare system and physical therapists everywhere.

Why do Medicare auditors assess 'skilled therapy' as a criteria of payment? Because they lack an alternative measure of value.

Evidence based physical therapy, such as classification decision rules, have been shown to improve outcomes, decrease expensive testing, medication use and invasive procedures.

Can physical therapists avoid arbitrary, punitive Medicare audit denials by documenting the use of classification predictor variables and decision rules in the plan of care, daily notes and discharge?

Couldn't a commitment from Medicare to "immunize" physical therapists who document evidence based therapy from the 'skilled therapy' criteria of Medicare audits prompt a sea-change in clinician behavior to adopt evidence-based methods more quickly?

Medical doctors and legislators have sought a similar immunization, based on evidence based care, from the current administration as regards defensive medicine.

Why couldn't physical therapists, the only doctoring profession subject to time-based CPT codes, put forth similar argument as regards Medicare audits?

Thank you for your consideration,

Tim Richardson, PT

Can Evidence Based Medicine Save Physical Therapy From 'Skilled Therapy'?

Can powerful new tools used by physical therapists prevent a Medicare audit?

If you write in your note tests that predict the outcome of treatment could that note be exempt from a "partial denial of a therapy claim" that requires oodles of handwritten narrative "trumpeting clinicians' concerns"?


Rather than trumpeting your concern in writing wouldn't you prefer to spend time thinking about how to get your patient better?

What new ways could you think of to provide 'value' to America's struggling healthcare marketplace?

Sources of Value in Physical Therapy
Old	New
Osteokinematics	Manipulation predictor variables
Gait analysis	Gait Velocity measurements
Narrative descriptors of "assistance"	Self-report scales (eg: ABC test)
Falls history for predicting future falls risk	Testing specified populations with known pre-test probabilities of falling down using tests with known likelihood ratios
Pathology model	Biopsychosocial model
Physicians' diagnosis	Physical Therapy Diagnosis

Much as physicians inflate health care costs with defensive medicine so to are physical therapists forced to waste precious time, money and energy with defensive documentation. Most would agree that documentation doesn't add 'value' to healthcare.

Even if you get your patient better in a reasonable time frame using evidence based physical therapy Medicare can come in and retroactively snatch away your payment dollars if you haven't trumpeted your concern in your notes and charts that each and every intervention is 'skilled' - nevermind that no uniform definition of 'skilled therapy' exists.

Defensive Documentation and Defensive Medicine

The American Medical Association as gone on record saying it will support legislation aiming to shave costs on defensive medicine by providing immunity from lawsuits for physicians who practice evidence based medicine. Health and Human Services Department economists estimate America could save $60-108 billion per year with malpractice reform.

The Health Care OverUse Reform Today Act (HealthCOURT Act - H.R. 3372) contains language that provides immunity from lawsuits to physicians who practice evidence-based medicine. It's purpose is to

"...establish an affirmative defense in medical malpractice actions based on compliance with best practices guidelines"

The HealthCOURT Act may not make it out of committee but Democrats seem willing to trade some aspect of malpractice reform for passage of a larger health care reform package.

The Medical Group Management Association (MGMA) sent this letter to Congress in May 2009 outlining their position on the use of evidence based guidelines and malpractice reform:

"Allow use of evidence-based guidelines to provide mitigating protection in professional liability cases.

In some circumstances allow these guideless to offer immunity."

How does Defensive Medicine relate to "Skilled Therapy"?

Why did Medicare chose to use a 'skilled therapy' criteria to evaluate your notes and charts? Because they had no alternative source of value!

Today, in 2009, physical therapists create value by assigning patients to classification treatment groups based on the presence or absence of statistically determined predictor variables. Physical therapy evidence is much better today than it was 15-20 years ago when Medicare auditors first began scrutinizing PT charts and notes, en masse.

One of my blog readers asked me not long ago...

"If a physical therapist is performing the therapy then isn't it, by definition, skilled therapy?"

I wasn't sure whether I should cry or laugh at the innocence, the naiveté displayed by this statement.

Over 40% of PT charges are reported to lack documentation supporting 'skilled therapy' - the result is 'maintenance therapy' unbillable to Medicare or most third party payers.

Skilled therapy has been in the Medicare Manuals since at least 1988, according to my research. The enforcement of skilled therapy, however, by the self-appointed police of documentation, those ghosts of past PT professors professing to know, from your notes, the level of your intent, skill, intelligence, care and effort that went into getting your patient better has only emerged since the early part of the 21st century.

Skilled therapy emerged from skilled nursing facilities where many people went following an acute hospitalization. Medicare began in 1965 as a program for treating acute, short-term medical problems for which a cure could be expected. For those persons, with 2-5 chronic conditions like...

• congestive heart failure
• obstructive pulmonary disease
• diabetes
• hypertension
• mental disorders

...the costs are many times higher than average and the expected improvement is less than average.

Often, there is no 'cure' for these conditions so Medicare mandated 'skilled therapy' as a way to ensure that certified professionals provided services and that patient safety was maintained.

Skilled Therapy and 'Progress'

Progress, the "improvement standard" so often unattainable in skilled nursing, is required in outpatient physical therapy. Getting and keeping people living independently keeps them in the lowest cost healthcare setting in America, their homes.

Nevertheless, local contractors have been criticized for applying an "improvement standard" as a way to deny needed care and save money...

"...for certain services, such as outpatient therapy services, Medicare's policies impose improvement standards that are inconsistent with the statute.

The Medicare statute does not demand a showing of improvement to find services medically necessary or to cover treatment of an illness or an injury.

The statutory criterion for treatment of an illness or injury applies regardless of where the covered service is provided, be it in a skilled nursing facility, at home, or as an outpatient."

An improvement standard in outpatient therapy clinics is less problematic today than it was when those words were written (2003). Today, about 48% of physical therapists use outcome measures - most of those are probably self-report measures like the...

• OPTIMAL scale
• Oswestry scale
• Fear-Avoidance Beliefs scale
• Lower Extremity Functional scale
• Shoulder Pain and Disability scale

Self report measures are the the main component in computerized patient assessments designed to replace Medicare fee-for-service within the next five years. One of their benefits is their ability to show need (medical necessity) and progress (improvement).

But, skilled therapy remains problematic.

Today, the search for 'skilled therapy' in PT notes and charts is an arbitrary scavenger hunt - paying off for auditors in daily notes when the PT is tired, busy, brief or vague.

Why not use specific evidence-based criteria: numbers, valid tests & measures, standardized outcomes and daily measurements centered on patient function?

I recommend physical therapists trade our allegiance to our 'old' practice patterns, based on observation and experience, for 'new' evidence based predictive models in exchange for immunity from the scourge of skilled therapy denials in Medicare audits.

The 10 Most Important Words in Evidence Based Physical Therapy

Bias – the systematic deviation from the truth.

Atun Gawande, MD said it this way:

"Three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes.

The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly.

It is unduly swayed by desire and emotion and even the time of day. It is affected by the order in which information is presented and how problems are framed."

Diagnosis is to “discern” or “distinguish” the nature of the patients’ problem. The original Greek word meant “to learn”.

In physical therapy, diagnosis is the process of integrating data obtained from the patient examination in order to treat and inform the plan of care, perform interventions and to make a prognosis (prediction).

Gold Standard – a test that is assumed to be valid can be compared to the measure of interest. In TBC, outcomes are the measure of interest. The manipulation and stabilization derivation studies used a 50% improvement in the Oswestry Disablement Score as the gold standard.

Many medical gold standards are imaging findings because medical tests are trying to confirm a pathoanatomic diagnosis.

Pretest Probability – the prevalence of a disease in the population (of your patients) at a given point in time. Steven McGee, in Evidence Based Physical Diagnosis states:

“Pretest probability is the starting point for all clinical decisions.”

Positive Likelihood Ratio “describes how probability changes when a test finding is present.

Findings whose LR is greater than one increase the probability of disease; the greater the LR the more compelling the argument for disease.” (Steven McGee)

The relationship between the finding and the diagnosis/outcome is defined numerically by the positive likelihood ratio.

Negative Likelihood Ratio “describes how probability changes when a test finding is absent.

Findings whose LR lie between zero and one decrease the probability of disease; the closer the LR is to zero the more convincing the finding argues against disease” (ibid)

The relationship between the finding and the diagnosis/outcome is defined numerically by the negative likelihood ratio.

Cookbook Medicine - a term used to deride the algorithmic simplicity of evidence based medicine, usually by those who prefer an observational, personal or ambiguous approach to decision making.

Diagnostic Perfection - the 'elusive search for diagnostic perfection' is defined by the test that identifies all patients with the condition of interest and rejects all patients without the condition of interest.

This impossible ideal is numerically defined by a test with a sensitivity and a specificity of 1.0.

A culture of measurement is another ideal that may be possible.

New tools have been described that trump the puny skills I graduated with in 1992 (eg: MMT) - perhaps the physical therapy profession is reaching a critical mass where measurement will become the standard and not the ideal.

Compliance – a legalistic term rather than a clinical term. Compliance cannot be memorized or practiced according to evidence-based standards.

Compliance is an ongoing, evolving process of the following:

1. self-audit
2. standardization
3. accountability
4. training
5. corrective action
6. communication
7. publication of your work

Physical therapy managers struggle trying to balance the paperwork burden of compliance and optimizing the therapists' time treating patients. More paperwork usually make the corporate lawyers happy while more time treating patients makes the therapists and the patients happy.

Ironically, too much paperwork forces corporate PTs and hospital PTs to rely more on unskilled aides, which may increase audit liability when you're caught.

So, how come compliance is an important word in evidence based physical therapy?

Well, consider this...

Recently, the incoming American Medical Association President Dr. J. James Rohack declared...

"Defensive medicine is another cost driver in the health system that will only abate with medical liability reform. For example, adherence to nationally recognized evidence-based guidelines can reduce the ordering of unnecessary tests if physicians no longer have to fear merit-less lawsuits.

President Obama has recognized the need for liability reform, and we urge Congress to include effective liability protections when guidelines are followed."

What if we recognized that 40% of physical therapy Medicare denials are "maintenance therapy" based on an auditor's judgement of a PT note. The note may appear "unskilled" since therapeutic exercise is, by nature, repetitious.

The physical therapy plan of care could appear repetitive even though the patient gets better, goals are met and outcomes improve.

Medicare audits and audit protection activities are a cost driver (part of the estimated 31% administrative costs in health care) that will only abate when Medicare stops auditing the process of how physical therapists deliver care (eg: "skilled" care, 8-minute rule, -KX & -59 modifiers, etc.) and starts looking at the outcome of care.

How much health care value will be unlocked when physical therapists are free to focus on patient outcomes instead of writing down every set, rep, position and variation of treatment we prescribe?

What process do auditors use to evaluate physical therapists charts? Could that process be subject to bias?

American medicine has recognized the need for an outcomes oriented system and we urge Medicare auditors to go easy on physical therapists when evidence based guidelines are followed.