Can EMRs Improve the Physical Therapy Experience?

"With great power comes great responsibility", quoted Heidi Jannenga, PT, MPT, ATC/L at the WebPT Evolve meeting in Orlando, Florida on October 18th, 2013.

Mrs. Jannenga was citing the explosive growth of the WebPT electronic medical record (EMR).  She mentioned the possibility that the WebPT user base at their current growth rate could actually overtake the number of physical therapists who are members in the American Physical Therapy Association.

Currently, WebPT has almost 27,000 therapist users who have generated over 38 million patient records since 2008.  WebPT claims that this is one of the largest repository of therapy outcome data in the world.

At the Evolve meeting in Orlando, Mrs. Jannenga and her husband Brad Jannenga, President, and CTO of WebPT had brought together a group of national-level physical therapist speakers. They spoke about Medicare compliance, internet marketing and key business metrics. The speakers delivered their own, original content.  They did not appear biased for or against any commercial EMR. 

I went to this meeting for two reasons: to prepare for an invited blogpost for the Technology Special Interest Group of the American Physical Therapy Association and as a user of WebPT trying to better understand the use of technology in the physical therapy clinic.

The meeting was pretty heady stuff, presented at the fabulous Peabody Hotel on International Drive in Orlando.  I would recommend anyone interested in learning about electronic medical records to attend this meeting.  WebPT opened the session for free to all interested parties.  Plus, they fed us dinner. 

This was the seventh Evolve meeting. The first one was held in Phoenix, AZ in October 2011. There have also been free Evolve meetings in Long Beach, CA, Palo Alto, CA, Chicago, IL, New York City, NY, Jersey City, NJ and Orlando, FL. WebPT will be holding more next year and will update their website with every new event.

To temper all the enthusiasm for electronic medical records however, I must show my readers some sobering facts that have recently come to light about the health information technology sector.

Do EMRs Add Value?
The idea that electronic patient notes will speed up therapy documentation by improving on handwritten notes just seems reasonable. But, new stories of expensive electronic medical record  cost overruns keep popping up in the media. To be fair, most of these stories are on the hospital side of the healthcare industry:

Adoption of expensive electronic medical record systems may hurt a hospital's bottom line, despite promises that the new systems will increase efficiencies and lower costs.  

Yet another hospital is reporting that the high cost of implementing a new EMR is having a negative effect, with Henry Ford Health System reporting its investment in Epic being a major factor in a 15 percent decrease in net income--from $62.9 million in 2011 to $53.1 million in 2012. From FierceEMR

Copy and Paste or 'Sloppy and Paste'?
There are additional concerns with the current generation of EMRs that allow essentially unrestricted copy-and-paste functionality between different dates of service. The clinician is trained to "document everything" which is almost too easy with computers. There is concern that patient information is not accurate.

According to a recent article in the journal of the American Health Information Management Association (AHIMA) called Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications

"Seventy-four to 90 percent of physicians use the copy/paste function in their EHRs, and between 20 to 78 percent of physician notes are copied text...  

It's become such a compliance and payment problem that the U.S. Department of Health and Human Services Secretary Kathleen Sebelius together with Attorney General Eric Holder wrote a letter last year to industry medical groups underscoring the seriousness of doctors "gaming the system, possibly to obtain payments to which they are not entitled."

'Note Bloat' Made EZ with EMRs
Several physicians complained about "note bloat", at an October 9th meeting of the College of Healthcare Information Management Executives (CHIME), where they said the content of the electronic note in the EMR lacked value because it was not "concise, complete and informational".

One example cited by Jim Venturella, CIO of the University of Pittsburgh Medical Center (UMPC), was a concerted effort by the  hospital to move physician documentation from paper to a Cerner EMR, between 2009 and 2012.

The new system produces 3.4 million notes a month in their inpatient EMR and 4 million notes in their ambulatory EMR. But in a survey of nearly 2,000 UPMC clinicians, less than half of respondents thought that the notes were valuable for patient care. (Healthcare IT News)

Is This the Year of the 'Great EMR Switch'?
More physicians and physical therapists are using EMRs.  Currently, the Centers for Disease Control and Prevention (CDC) estimates that 72% of practices in 2012 use an EMR, up from 54% in 2011. 

However, many providers are dissatisfied with their current EMRs and 17% of physicians are planning to switch their EHR within the next year according to the industry survey Black Book Rankings. 

The federal Meaningful Use mandates have created a 'one-size-fits-all' EMR model that contains too many features that too many providers don't want. 

Interestingly, specialty providers expressed the highest dissatisfaction with the current crop of EMR vendors due to the lack of customizable features.

Will specialty vendors, such as WebPT, survive the expected industry shake-out by narrowly focusing on the needs of therapists and their patients?  Can WebPT control and mitigate the abuses expected to arise from unrestricted copy-and-paste?   Will a WebPT note reduce 'note bloat'?

I suspect the market will shake out leaving the less fit EMRs in the dust. Many of the smaller EMR companies suffer from the same weaknesses that small physical therapy clinics and small businesses have faced recently - inadequate capitalization and a small user base.

The strength of the EMR industry is probably based on the same thing other industries are based on: sound balance sheets and a good cash flow.  Even great technology can't trump the ruthlessness of market forces.

According to surveys comprised from 16,000 EHR users and 550 EHR vendors by Black Book Market Research:

"Nine of 10 EMR industry insiders agree that the majority of EMR vendors currently implemented will fail to sustain operations by 2017.

Eight of ten EMR industry insiders predicted that well-funded, inventive small vendors that carve a niche in specialist sectors should have better foundations for viability than those who failed to resolve the fundamental flaws caused by being all things to all physicians."

I suspect WebPT will continue to gain market share and will remain a leader in the therapy EMR space.  They have a good product.  Their continued dominance will depend on their ability to remain responsive to the needs of their customers. 

Pop Quiz! Who can identify the quote Heidi used for her vision for WebPT at the beginning of this piece?

What has the American Physical Therapy Association done for you lately?

Patient stories...

Physical therapists hear these stories every day but the APTA is helping to put patient stories where they will do some good - in front of legislators who can determine your Medicare reimbursement.

The APTA coordinated a recent practice visit with the office of Federal legislator Vern Buchanan (R-Bradenton) on Tuesday, August 6th at a private physical therapy clinic in Bradenton, Florida. The following stories are a good example of what the legislator heard that day...

The 82-year old female patient gave a lucid, moving story about how her physical therapist had 'saved her life' by helping her remain living at home after a fall and a hip fracture. She mentioned she was already at the 'hard cap' of $3,700 in 2013 and didn't know how she could continue to pay for the services of her therapist even at the reduced frequency of one time per week.

The male patient, a retired veterinarian, told a very funny story of dislocating his shoulder by, believe it or not, walking his big dog. He was offered imaging and surgery by an orthopedic surgeon who owns therapy services. The patient said he wanted to think about these two options and, in the meantime, could he get a referral to physical therapy? That was three months ago and he now has full passive ROM. He is in no pain. He is also at the 'hard cap' but he credits his physical therapist with preventing what was, in his opinion, an unnecessary surgery.

Therapy Cap is top-of-mind for physical therapists because we deal with it every day but most legislators and their staff have many other responsibilities. Patient stories help make the recent Therapy Cap legislation REAL for members of the Congress by putting a human face on the problem.

The Medicare Access to Rehabilitation Services Act (HR 713) was recently introduced in the House of Representatives by Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA).  HR 713 would permanently repeal the $1,900 therapy cap imposed on physical therapy, occupational therapy, and speech-language pathology services.

We asked Congressman Buchanan to support HR 713 by attaching it to another bill that is gathering momentum in Washington DC.   The Medicare Physician Payment Innovation Act (HR 574), introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV) provides the following:

• repeal and replace the flawed Sustainable Growth Rate (SGR) formula.
• a clearly defined path to permanent Medicare payment reform.
• it includes a multi-year period of payment stability for Medicare providers.
• a stipulated annual payment rate increase of 0.5% to the Physician Fee Schedule.
• CMS will test and evaluate several alternative payment systems including the Alternative Payment System for therapy proposed by the American Physical Therapy Association. 

For the first time in many years, there is bipartisan support for repealing and replacing the SGR and fixing Medicare reimbursement for physical therapists via HR 574.  There is also a chance to fix the Therapy Cap by attaching HR 713.

To improve our chances you need to contact your legislators with your patient stories.   

Sustainable Growth Rate Replacement On Sale at the #PPSFlyIn !

Like treasure-seekers at a sidewalk scavenger sale physical therapists can get a little excited about the potential for meaningful Medicare payment reform this summer. 

The flawed Sustainable Growth Rate (SGR) formula is on sale for a limited time only and the Congress can buy this dusty artifact from the 1997 Balanced Budget Act with new legislation in 2013.

The Medicare Physician Payment Innovation Act (HR 574) will provide a clearly defined path to payment reform as well as a period of payment stability necessary for physical therapist and physician practices to transition to an alternative payment system, reports Jerry Connolly from the American Physical Therapy Association Private Practice Section Advocacy Fly-In in Washington DC.

The cost to replace the SGR has decreased over the last three years because the 2009 Great Recession and ObamaCare have both driven down healthcare cost growth. The decrease in cost growth, in turn, changes the 10-year estimate to replace the SGR.  This estimate is calculated by the Congressional Budget Office which announced that the new price is $139 billion, down from $330 billion.

Only in Washington DC is $139 billion seen as cheap.  It's like finding an old vinyl copy of Led Zeppelin's 1971 Stairway to Heaven for $2!

The SGR is used to calculate physical therapists' Medicare payments.  The SGR has also been a big distraction for the Congress every year as provider organizations lobby to prevent ever bigger Medicare cuts. 

The 2014 adjustment is projected to be negative 24%!  Now that's cheap!

Physical Therapists and America's Disability System

Thanks to Adam Rufa, PT at ForwardThinkingPT.com for pointing our attention to the This American Life episode on March 22nd, 2013 called Trends With Benefits.  This episode is about disability in America.

Read Adam's excellent post about the 14 million Americans who don't show up for work every Monday morning but also don't show up in the official Federal unemployment numbers.

Rising disability is a 30-year American trend and 250,000 new Americans are applying for disability each month.

Perhaps the most backwards part about the disability system in America is there are only two ways off: you get so old that Social Security and Medicare take over or, you die.

Amazingly, the disability program doesn't provide physical therapy benefits to return you to your prior level of function.

Physical therapists should listen to this 57:26 minute podcast by reporter Chana Joffe-Walt for a very interesting tutorial on America's disability system.

Perhaps physical therapists  can understand our patients' perspective a little better if we understand the system we all live in.

'Blow Up' Physical Therapy Documentation, too

Hate G-codes? Think the Severity Modifier are a waste of your time? Dr. Halamka shares your pain:

"The way we document in medicine has grown up over decades for medical reasons, for billing, for medical-legal justification,” said Dr. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston. “You wind up with 17 pages of replicated and duplicated and challenging-to-read documentation.  

I propose we blow up the way we do documentation altogether and replace it with a Wikipedia-like structure.”

Dr. Halamka made these comments in the article EHRs: “Sloppy and paste” endures despite patient safety risk in American Medical News, February 4th, 2013. The article discusses rampant 'cloning' of patient notes in electronic medical records.

Dr. Halamka's statement references an article published in the February 2013 edition of Critical Care Medicine:

"The study examined 2,068 progress notes by 62 residents and 11 attending physicians of 135 intensive care unit patients in a medical center in Cleveland, using plagiarism detection software. 

The researchers found that more than four-fifths (82 percent) of the residents and three-fourths (74 percent) of the attendings' notes contained at least 20 percent of copied information." 

Dr. Halamka seems to go beyond the cloning issue - that could be solved by merely disabling the 'copy-and-paste' function in the EMR.  He wants to 'blow up' the whole documentation format which, I assume, includes SOAP.

SOAP has survived in medicine this long, I think, because medical notes are substantially more 'data-rich' than physical therapy notes. Another doctor could read the note and, despite its limitations, still glean sufficient data to make decisions. Physical therapy notes, however, are 'data-poor'.

But, 'cloning' is nothing new.  Physical therapists for years have handwritten 'meaningless drivel' on paper notes, according to Anthony Delitto, PhD, PT in Are Measures of Function and Disability Important in Low Back Care?

Any PT manager who has ever done a chart audit knows that many PT notes are repetitive and uninformative.  Why?  I'm not sure but I suspect that training and inertia are big factors.

Physical therapy documentation is way past its expiration date.  My students tell me they are still trained to write notes the way I was taught in 1990!  Don't believe that physical therapists are stuck on SOAP?  Read "What is a SOAP Note?" written in 2008 with over 17,000 page views!  SOAP notes were first described in 1968!

Physicians have adopted EMR software more quickly than physical therapists.  It is natural that they would use electronic  tools like 'copy-and-paste' to speed-up their work.  But, 'copy-and-paste' becomes 'sloppy-and-paste' when new technology catches up to our old, inefficient documentation format.

Many Electronic Medical Record (EMR) designers copied the SOAP format when they moved from paper to electronic to ease the burden on providers. Doctors could learn the new computer interface as long as they didn't also have to learn a new documentation format.

Physical therapists seem comfortable sticking with our traditional narrative-driven, SOAP-based format because it is comfortable, not because it is the right thing to do.

I would also like to see better ways of recording the patient experience and making better therapeutic decisions.  I think electronic communication tools can help providers do that.  But, medicine is substantially different from rehab.  Any electronic solution physicians adopt is unlikely to be ideal for therapists.

What ideas do readers of this blog have?  Video?  Photos?  Self-reports?

How can therapists collect better data?

If physical therapists don't come up with better ways of documenting then the government will do it for us.  You know what that gets us: G-codes and Severity Modifiers.

Live Functional Outcomes Webinar Now at PhysicalTherapy.com

How to Effectively Use Outcomes Questionnaires for Federal Quality Reporting, Better Productivity and Better Outcomes is a recorded webinar that will be also be aired live at PhysicalTherapy.com.

The webinar will start at 8am EST on Thursday, December 13th, 2012.

Membership is required and you can view the recorded webinar at any time, at your convenience.

Get ready for 2013 Functional Reporting or PQRS using standardized outcome measures with How to Effectively Use Outcomes Questionnaires for Federal Quality Reporting, Better Productivity and Better Outcomes.

Patients Win! Maintenance Therapy Settlement Gets Preliminarily Approval!

Physical therapists' patients can take cheer this holiday season, nestled all snug their beds, with the knowledge that Maintenance Therapy will still be here through Christmas.

The class action lawsuit filed and won by the Center for Medicare Advocacy has tremendous potential to simplify therapy decision making by managers, therapists and patients.

Just in time, too, considering the Byzantine complexity brought by Medicare Manual Reporting and, now, Functional Reporting for 2013.

According to the Center for Medicare Advocacy, on Sunday, December 9th, 2012:

"A proposed settlement agreement was filed in federal District Court on October 16, 2012. On November 20, Chief Judge Christina Reiss of the District of Vermont signed an order preliminarily approving the settlement agreement. 

By December 10, 2012, notice of the settlement will be posted on the websites of numerous organizations, including the seven national organizations that served as plaintiffs in the case, which will alert advocates and beneficiaries to the terms of the settlement."

Many observers believe that Medicare will somehow acquit themselves of 35-plus years of illegal behavior and continue to deny care based on the just-overturned "Improvement Standard".  The CMA announcement, however, implies that the class participants, not Medicare, are the ones in position to accept or deny the Settlement.

"Class members will be able to file written objections to the settlement. 

The court will hold a Fairness Hearing on January 24, 2013 'to determine whether the settlement agreement is fair, reasonable and adequate,' after which it is hoped that the judge will issue an order permanently approving the settlement agreement."

The Settlement only applies to the illegal Improvement Standard, or the idea that people must make significant and measurable gains in function in order to continue receiving therapy services. Two further conditions still apply: the services must be of sufficient complexity that a lesser trained provider could not safely perform the care and the patient must still demonstrate that the services are medically necessary.

I've had conversations with therapists who support the Improvement Standard on the grounds that "we can't afford to expand Medicare right now".

The Settlement is not an expansion of Medicare. The Settlement is a clarification of the Congressional intent to provide Medicare beneficiaries with a level of care that would not leave them disabled and institutionalized.

For my entire 20-year career, I've been told by well-meaning PT managers and staff that we must "show progress" in order to treat our patients. In turn, my managers had been told by the Medicare Carriers and Fiscal Intermediaries (mainly Blue Cross/Blue Shield and other commercial insurers) that claims would be denied if the patients didn't "show progress".

It turns out that the insurance companies, acting under the aegis of Medicare, were breaking the law.

Here is testimony the the CMA website:

"These changes [from the Settlement] are extremely meaningful, as my mother has repeatedly been denied the ability to continue the physical therapy she needs in order to prevent further deterioration of her condition. 

It has been extraordinarily frustrating, and after the last cessation of Physical Therapy and subsequent deterioration actually endangered her life, her quality of life was greatly affected, resulting in extremely expensive 24/7 care. 

If she could have kept her PT services, this would not have happened!" 

-Veronica, New Hampshire

If the Settlement sticks (as I think it will) it will be the best Christmas present of my entire career.

Maintenance #PhysicalTherapy Paid by Medicare?

This may be the biggest change to Medicare affecting physical therapists since the March 23rd, 2010 passage of the Patient Protection and Affordable Care Act (PPACA).

Medicare may now be forced to adhere to the statutory language enacted by the Congress instead of the more restrictive policies adopted by individual Medicare Administrative Contractors (MACs) who limited therapy services because the patient did not show progress.

In other words, Medicare may now be forced to pay for "Maintenance Therapy".

A proposed settlement announced today at 2pm by the Center for Medicare Advocacy (CMA) will be held in Washington DC. According to the CMA:

"Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for such services if they are needed to 'maintain the patient’s current condition or prevent or slow further deterioration,' regardless of whether the patient’s condition is expected to improve."

Physical therapists have long been told by Medicare Auditors that we must discharge our patients when they "plateau" and their function no longer improves. To be sure, physical therapists shouldn't use today's decision to ignore equally challenging documentation guidelines. Physical therapists still need to show "skilled physical therapy" and "medical necessity for physical therapy". This New York Times article discusses some of the new cost implications to Medicare of maintenance therapy.

However, the CMA has removed a significant barrier to care between physical therapists and their patients.

"For decades, Medicare beneficiaries – particularly those with long-term or debilitating conditions and those who need rehabilitation services – have been denied necessary care based on a so-called “improvement standard.” 

This illegal practice means that Medicare coverage for vital care is denied to thousands of individuals on the grounds that their condition is stable, chronic, not improving, or that the necessary services are for “maintenance only”. 

The Improvement Standard conflicts with the law."

This decision will impact patients and physical therapists in most settings, including the private practice physical therapy clinic, the home health setting, skilled nursing and the hospital outpatient setting.

What do you think? Are you in favor of Medicare paying for maintenance therapy?

Medical Apps for Physical Therapy

Video documentation of the physical therapy note is the future and the iPhone is the logical choice for the clinical handset.

Several apps have been developed that use the camera and video features of mobile devices to record patient function.

I reviewed a mobile app developed in 2011 and my review of this innovative mobile app is featured on the Medical App Journal.

Write me if you'd like to see your medical or physical therapy app reviewed.

Important reminders before completing the pre-approval of therapy services form

First Coast Service Options' (First Coast’s) Medical Review department is returning a high volume of pre-approval requests for therapy services forms due to inaccurate, incomplete, or invalid information. Requests that are returned will not be processed. Corrections must be completed and a new request submitted.

The following list has been developed to assist you in avoiding this situation. These are some things you should check for before faxing or mailing your form:

• Verify that you are submitting the pre-approval request during your appropriate phase. Pre-approvals may not be submitted earlier than 15 days prior to the beginning of your applicable phase. 
• Do not send in documentation without the completed pre-approval request form. 
• Do not use your own coversheet when faxing the pre-approval form. The completed pre-approval form will serve as your coversheet. 
• Do not split a single request into multiple faxes. All documentation for a single pre-approval request must be submitted together. 
• Do not submit duplicate requests. Physical therapy (PT), occupational therapy (OT), or speech language pathology (SLP) must be checked on the pre-approval form to indicate the therapy discipline that the additional days are being requested for. If a patient is receiving multiple disciplines (e.g., OT, PT) that you are requesting additional therapy days for, two separate requests must be submitted. 
• Provide the correct provider transaction access number (PTAN) and/or national provider identifier (NPI) of the applicable facility or individual depending on whether this is for a Part A facility/entity or Part B individual/performing provider. If listing a facility/entity, report the legal business name as reported to the Internal Revenue Service (IRS). 
• You must include the name and telephone number of the person to contact regarding the pre-approval request. Providers and therapists that are currently on any type of corrective action (e.g., probe, prepayment review, probe, prepayment review, zone program integrity contractor, etc.) process are not exempt from prepayment review and should consider whether the pre-approval process is beneficial for your office. 

Regardless of whether you receive a confirmation for approval or denial of additional therapy days, once the services are rendered and a claim is submitted, First Coast will request the medical records for review prior to determining whether payment will be made.

The Incredible Opacity of Physical Therapy

There is no setting more opaque than physical therapy.

Not cardiology. Not orthopedics. Not family practice. Many consumers don't even know what a physical therapist does.

"Did you have study to be a physical therapist?" asked my elderly patient yesterday. I've treated him, on-and-off, for the last four years. The blow-up version of my diploma from the University of Florida (Home of the Fight'n Gators!) occupies about one-third of the wall space in a prominent place in my clinic.

"Yes," I answered gently. "I did study. I went to physical therapy school," I said.

Part of the problem is that even physical therapists don't have a conventional way of describing what we do. Oh, we have jargon. We have "medical-ese". When two physical therapists or therapist assistants talk among themselves the language can get pretty technical - just ask any patient.

"You have a capsular pattern of left shoulder mobility limitation - I don't think it's tendinitis - but instead I think you have adhesive capsulitis."

"Oh," says the patient. "What does that mean?"

The other part of the problem is that physical therapists are trained to write, to record, our findings in a narrative summary that is supposed to describe the patient experience.

The following ridiculous note is the official recommendation of a Medicare auditor in 2009:

"Quadriceps strengthening into last 20 degrees of extension with mild manual resistance and proprioceptive cueing, 30 reps to fatigue, continues to decrease current extension lag and improve quality and duration of gait."

In the new, patient-centered health care world this narrative from the therapists' perspective is clearly inadequate. Worse, it fails to communicate the value of what physical therapists actually do.

Perhaps the answer to the problem of public perception and physical therapists' value can be solved by this out-of-the-box solution: OpenNotes.

OpenNotes has been studied in a new, year-long quasi-experimental study of 13,564 patients just published in the Annals of Internal Medicine:

"Electronic portals are increasingly used to provide patients with access to their medical records and to interact with the health care system.

In this study of doctors and patients who participated in a 1-year pilot program, most patients reported that the ability to read their doctors’ office notes was beneficial and wanted the program to continue. 

Most doctors reported little or no impact on daily workload or patient anxiety or confusion."

Some of the benefits of OpenNotes include the following:

1. improved doctor-patient relationships
2. improved patient satisfaction
3. no increase in workload

Let's take it one step further and increase the transparency and value of physical therapy notes. This specific recommendation for video notes comes from the authors of the Open Notes: Doctors and Patients Signing On:

"At home, patients of the future may review an unedited, automated, 2-camera shoot of a recent electronic or in-person visit to the doctor, and then discuss with family, friends, and the clinician how to modulate and finalize the note. 

Further ahead, such jointly generated and held records may evolve into a person's story over time, documenting health and illness from early days to the end of life. 

We expect that is where we are heading, but on a course filled with fits, starts, and unforeseen consequences. As the patient–doctor relationship moves forward, OpenNotes will almost certainly be on the road ahead."

Physical therapists can move forward toward this inspirational vision of the future by beginning to use video notes to record and document their patient experience.

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.

Legislative Meeting Kicks Off FLPTPP 2012

The Florida Physical Therapists' in Private Practice (FLPTPP) Legislative Committee Meeting kicks off the 2nd Annual FLPTPP Conference today, August 17th, 2012, at the:

Hilton Orlando Resort, Lake Buena Vista 1751, Hotel Plaza Blvd, Lake Buena Vista, Florida

I-4 corridor to the FLPTPP meeting in Orlando

The FLPTPP is hosting Phil Moe, South Dakota's Chief Delegate and Board of Directors' member.

As many readers of this blog are aware, South Dakota is one of three states that have recently enacted patient protection legislation to prevent insurance companies from charging patients excessively high copayments for physical therapy.

Phil will describe the legislative strategy his state association used to achieve their legislative success. The meeting starts at 5pm in the Hilton Palm 3 conference room.

On-site registration for the conference is available.

Physical Therapy and Health Information Technology

Physical therapy shown at 1:42.

Why Physical Therapists Should Make Diagnoses

"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the American Medical Association from John Barnes
CEO, American Physical Therapy Association

12/22/2009

Florida Physical Therapists Wanted to Speak to Legislators

The Key Contacts program of the Florida Physical Therapy Association (FPTA) is designed to put a physical therapist (PT) or physical therapist assistant (PTA) in every state legislator's office in Florida.

Each Florida legislator has an office in your district. Maybe your legislator has an office in your town.

We especially need therapists in the South Florida area.

The goal is to make politics personal so when the FPTA has an issue that needs support - such as the recently successful Temporary Licensure law - then we can reach out to the legislator.

But we need you to make that face-to-face contact.

The Florida Physical Therapy Association will be making strategic contributions to several legislators in anticipation of the 2013 legislative cycle.

You can set up a Practice Visit to meet you, your staff and your patients.

The FPTA may want to suport your legislator using FPTA Political Action Committee (PAC) funds.

Find out if your legislator in on the list by e-mailing Eric Chaconas, DPT.

Physical medicine and rehabilitation physicians targeted in probe of therapy services

First Coast Service Options Inc. (FCSO) conducted a widespread probe (WSP) review in response to an aberrant billing pattern for CPT codes and posted this notice June 12th, 2012.

Here are the codes with high error rates:

1. 97032 (Application of a modality to one or more areas; electrical stimulation [manual], each 15 minutes);
2. 97035 (Application of a modality to one or more areas; ultrasound, each 15 minutes)
3. 97124 (Therapeutic procedure, one or more areas, each 15 minutes; massage including effleurage, petrissage and/or tapotement [stroking, compression, percussion]) billed by specialty 25 (physical medicine and rehabilitation).

The results of the widespread probe yielded a 62 percent claim error rate.

The most common reason for an error to be assigned was insufficient documentation including failure to meet Medicare’s documentation requirements specific to therapy services.

As a result of the widespread probe findings, FCSO will implement a prepayment medical review edit for therapy services billed by physical medicine and rehabilitation physicians.

The following is a brief summary of Medicare requirements for therapy services:

1. Therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services.
2. Documentation must be legible, relevant, and sufficient to justify the services billed.
3. The patient receiving outpatient therapy services must be under the care of a physician/nonphysician practitioner (NPP). NPP signifies a physician assistant, clinical nurse specialist or nurse practitioner, who may, if state and local law permit it, and when appropriate rules are followed, provide, certify, or supervise therapy services.
4. Therapy services must relate directly and specifically to a written treatment plan.
5. The plan (also known as a plan of care or plan of treatment) must be established before treatment is started. The plan is established when it is developed (e.g., written or dictated).
6. The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded within the plan.
7. The Plan of Care shall contain, at minimum, the following information as required by regulation (42 CFR 424.24 and 410.61) See Pub. 100-02, Chapter 15, section 220.3 for further documentation requirements).
• Diagnosis
• Long Term treatment goals
• Type, amount, duration and frequency of therapy services
8. The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan.
9. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.
10. Long Term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care in the current setting.
11. When the episode of care is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified.
12. Goals should be measurable and pertain to identified functional impairments.
13. When episodes in the setting are short, measurable goals may not be achievable; documentation should state the clinical reasons progress cannot be shown.
14. The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a description of a specific treatment or intervention.
15. Where a physician/NPP establishes a plan, the plan must specify the type (PT, OT, SLP) of therapy planned.

Various entities may request documentation to support services billed to the Medicare program (e.g., Medicare administrative contractor [MAC], comprehensive error rate testing [CERT], recovery audit contractor [RAC], zone program integrity contractors [ZPIC], or the office of inspector general [OIG]).

Documentation in the Patient's Chart
The following documentation must be submitted in response to a request for documentation, unless the requesting contractor specifies otherwise.

1. Evaluation and plan of care (POC) (may be one or two documents). Include the initial evaluation and any reevaluations relevant to the episode being reviewed; Certification (physician/NPP approval of the plan) and recertification when records are requested after the certification/recertification is due;
2. Progress reports (including discharge notes, if applicable) when records are requested after the reports are due;
3. Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes). Daily treatment notes must indicate the individual modalities performed that day. Minutes must be documented for each modality that represents a time-based code and the total time in treatment must be documented.
4. A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands the reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation. If the patient is expected to exceed the therapy cap, the record must clearly indicate the medical necessity for the patient to receive covered services above the cap. Note: The excessive use of modifier KX (Requirements specified in the medical policy have been met) may indicate abusive billing.

Therapy services have their own benefit under section 1861 of the Social Security Act (“the Act”) and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals. Statute 1862 (a) (20) of the Act requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions -- other than licensing -- that would apply to a therapist.

Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology.

That means that the services of athletic trainers, massage therapists, recreational therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as covered therapy services.

In addition, there is no coverage for services provided “incident to” the service of a therapist. Although physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) work under the supervision of a therapist and their services may be billed by the therapist, their services are covered under the benefit for therapy services and not by the benefit for services “incident to” a physician/NPP. The services furnished by PTAs and OTAs are not incident to the therapist’s services. A physical therapist must supervise PTAs and an occupational therapist must supervise OTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. The service of a PTA and OTA shall not be billed as services “incident to” a physician/NPP’s service, because they do not meet the qualifications of a therapist. Only services provided by a licensed therapist or an individual who has completed an accredited PT or OT curriculum and are qualified for licensure may provide services “incident to” the physician/NPP.

Providers are encouraged to review the complete requirements for billing rehabilitation services found on FCSO’s Therapy and Rehabilitation Services local coverage determination L29399 (Puerto Rico and the U.S. Virgin Islands) as well as the requirements found in the Internet-only manual (IOM), Pub. 100-02 , Medicare Benefit Policy Manual, Chapter 15, Sections 220-230 .

The Future of Physical Therapy

"The future is already here - its just not evenly distributed"

William Gibson's most famous (and over-quoted) quote. He also coined the word cyberspace and won the Triple Crown of science fiction literature: the Nebula award, the Hugo award, and the Philip K. Dick Award for his first novel, Neuromancer.

But, today I want to tell you about some physical therapy writers - or, more accurately, their work.

First, is a new, fascinating article in PT in Motion called Virtual Realities: Visions of Science, Technology, and Physical Therapy - Virtual Realities beyond 2020.

You'll read about...

• augmented reality of stroke patients moving their limbs
• holograms of patients homes
• robots in the clinic
• exoskeletons helping kids walk
• and more...

And, this article I wrote for Advance for Physical Therapy called Future Electronic Medical Records (EMR) Directions that describes...

• video documentation of patient movements
• interoperable patient records in the PT clinic
• smart phones used easily in the PT clinic
• scheduling patients with text messages
• and more...

Its an exciting time to be a physical therapist.

Are you ready for it?

Task Force Recommends Physical Therapists Use Clinical Intuition to Screen for Fall Prevention

The U.S. Preventive Services Task Force (USPSTF) Recommendation Statement for Prevention of Falls in Community-Dwelling Older Adults was published May 28th, 2012 in the Annals of Internal Medicine and the author's found new evidence promoting...

"...exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (Grade B recommendation)"

An extensive evaluation or high-tech balance assessment is not necessary:

"In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (Grade C recommendation)"

Physical therapists should be able to use their clinical intuition to determine which patients are at high risk for falls and for whom physical therapy is medically necessary.

Medicare will pay for physical therapy that is medically necessary to prevent a future adverse event.

In some cases, the physical therapist may be able to apply the -kx modifier attesting that services are medically necessary over and above the 2012 $1,880 combined cap on speech and physical therapy.

Join Pitt DPT Students to #SolvePT

Be a part of the movement!

Add your voice to this Twitter conversation to determine what physical therapy will look like in the future.

Log on today, Tuesday May 22nd, 2012 from 9-10 pm EST the topic will be:

Does Alphabet Soup & New Terms Erode Our Profession?

I recieved this image yesterday in an e-mail from the students at the University of Pittsburgh who have put their full weight behind the movement.

• Rock the boat
• Find solutions
• Be the change