When should you use the OPTIMAL Scale?

The Case of Mr. Spooner

Some readers of this blog have posited that you should never, ever use the OPTIMAL scale because it is "crap" and not a useful tool for clinical decision-making.

The shortcomimgs of the OPTIMAL have been previously discussed here and are well-known.

OPTIMAL is a 'setting-specific' tool for activity limitations affecting the upper body, lower body and trunk.

That is, OPTIMAL is appropriate for patients who can ambulate into your clinic, irrespective of wheter their conditions affect their knees, hips, spine, shoulder, etc.

OPTIMAL might not be appropriate for patients in acute care or in long term care.

The Case of Mr. Spooner

The reason I bring this up is because Mr. Spooner (see above) came into my clinic today.

Mr. Spooner had the following physician's diagnoses:

1. Gait Disorder
   
2. Post-op lumbar laminectomy
   
3. Cervical herniated disc
   
4. Leg weakness

Normally, for these diagnoses, I would, provisionally - based upon the findings, decide to use these outcome scales, respectively:

1. Modified Falls Efficacy Scale
   
2. Oswestry Scale
   
3. Neck Disability Index
   
4. Lower Extremity Functional Scale

These outcome measures are "condition specific" - that is, the physical therapist chooses the scale based on how well she feels the scale reflects the activity limitations discovered in the initial evaluation.

Widespread Panic

But, poor Mr. Spooner - he was a mess!

I didn't want to have him fill out four separate pages of data. He just wanted to feel better - not write a book!

Fortunately, our clinic has been using the OPTIMAL scale for almost three years - we have only recently started using the condition-specific measures for single-diagnosis cases.

Mr. Spooner was done with his questionnaire in 3-4 minutes and on his way.

We had valid, reliable data for use as an outcomes baseline. If, at some point, one of his conditions becomes more acute or refractory to treatment we may ask him to fill out one of the condition-specific measures.

Is OPTIMAL a last resort?

Better than a last resort OPTIMAL is a tool for clinical decision-making.

Not the best tool you have - and certainly not the worst.

Like any craftsman, you may choose to use your tools to gain the best patient outcomes you can.

You decide.

Is your physical therapy 'cookie cutter'?

I appears that a 'cookie cutter' approach to therapy services is not a unique problem to physical therapists.

This post by Kori E. Carson Dean, Ed.S states the problem of the 'one-size-fits-all' approach to therapy services as it applies to special education.

Apparently, Occuptional Therapy (OT) and special education services have 'rules, laws practices' that adhere to the philosophy of the Individuals with Disabilities Education Act.

These professionals also seem to approach professional autonomy in the same way that physical therapists approach the Doctor of Physical Therapy (DPT):

"The therapist is correct that a (medical) doctor cannot dictate the amount of service time the therapist is required to provide."

Since much of current physical therapy research is focusing on the question of classification and treatment group assignment I am inclined to ask:

"At what point do standardized 'treatment groups' become a 'cookie-cutter' approach?"

I answered a question today on the Yahoo Groups PT Manager list-serve.

Hello Group,

I am looking for any information or suggestions on Treatment Diagnoses vs. Medical Diagnoses. I am having difficulty finding many good treatment diagnoses for my patients who do not have obvious gait abnormalities or radicular weakness secondary to their conditions.

Because our population is mostly spine we tend to end up with more medically based diagnoses such as disc herniation or sciatica.

I would appreciate any feedback or suggestions on this.

New Grad

******************

Dear New Grad,

We also treat a lot (~50%) spine and we get lots of anatomic (medical)
diagnoses (eg: SI strain, HNP, sciatica).

A few years ago we started mandating a physical therapists' diagnosis
for every patient.

Now, we are able to do the following:

- improve treatment selection
- improve goal-setting
- demonstrate medical necessity
- show progress
- show skilled decision-making

...using a baseline activity scale (OPTIMAL) and a disablement model
(ICF).

We started studying these issues for our Medicare compliance program
and then we noticed patients were getting better quicker.

We use a problem list, not a diagnostic label.

I'll use 'shoulder bursitis' as an example.

We would diagnose "Difficulty Lifting & Carrying due to the following:

- weak shoulder external rotator muscle
- weak shoulder flexor muscle
- stiff shoulder flexion ROM
- stiff trunk sidebending ROM

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

- Ther Ex (97110) to strengthen shoulder flexors and external rotator
muscles.
- Manual Therapy (97140) to improve ROM of shoulder flexion and trunk
SB.
- Neuro Re-ed (97112) to distinguish shoulder rotation from trunk
rotation.
- Ther Acts (97530) for Lifting without scapular elevation.

Goals:

1) Improve shldr. ER from X to Y to improve Lifting from 4/5 to 3/5.
2) Improve shldr. flexion from X to Y to improve Lifting.
3) Improve trunk SB from X to Y to improve Carrying from 4/5 to 3/5."

(Note: OPTIMAL estimated MCID = 1.0)

In my state (Florida) my carrier (FCSO) does not use
diagnostic 'crosswalks' and I've not had denials based on using the
physician's diagnosis.

We'll have ICD-10 before physical therapists get to bill using the
ICF code set so I'm not even sure the diagnosis on the claim form
matters.

Physicians appreciate the problem list because they don't check this
stuff - no one else does either.

Linking Activity Limitations to Impairments is the physical
therapists' diagnosis.

Physical therapy diagnosis is a sustainable competitive advantage in
the health care market.

Tim

How do physical therapists make decisions?

Physical therapists (PT) usually treat 11-15 patients per day in outpatient orthopedic clinics.

Most PTs in the United States still use a pen-and-paper approach to note writing.

We scribble all day long in between running to patient treatments.

Medicare only has these written notes to examine to determine if the physical therapy treatments are worth paying for.

What do most PT charts look like and what decisions do they reflect?

Get some perspective

Step back for a minute.

Stop writing your note.

Stop being a PT or PTA.

Look at your chart.

What does it look like?

Is it organized?

Neat?

Sequentially organized?

Are the most important documents on top?

Does it look like you chart is designed for fast, efficient treatment?

Or, does it look like your chart is designed for fast, efficient decisions?

What do skilled physical therapy decisions look like?

Your skilled physical therapist decisions are what Medicare is paying for.

Treatment is secondary to your decisions.

Make the chart work for you.

Set up your chart so that evidence of decision-making is foremost.

Put your goals at the front of the chart.

Make decisions about goals in the daily note. If you still use a SOAP note the Assessment portion should reflect progress towards goals.

Make your initial measurements accessible. Put your dictated Plan of Care where you can get to it easily (hint: not at the back of the chart).

Two types of measurement need to be accessible:

1. Impairment in body structure and function (ICF)

2. Activity and participation limitations (OPTIMAL)

Put these near the front of the chart.

Some therapists feel that the back of a double-sided, flip-type paper chart is just as accessible by grabbing the whole stack of paper and flipping it up.

Perhaps it is.

I think that putting your goals and measurements at the back of the chart however sends the subtle message that you see writing about goals as less important.

Goals are less apparent and less evident at the back.

The presentation of your chart should reflect your intent.

What is your intent?

Decisions or treatment?

Decisions are more defensible.

*****

To get an incredibly detailed, voluminous, technical and shelf-worthy resource on physical therapy do-it-yourself Medicare compliance go to the

Compliance Program for Individual and Small Group Physician Practices

by the Office of the Inspector General.

To get a compliance program written by a physical therapist for physical therapists go to

BulletproofPT.com

written by Tim Richardson, PT.

Is Ultrasound Medically Necessary for Physical Therapy?

Do you use ultrasound on your patients?

Why?

How often or how much?

When do you stop ultrasound treatments?

What are the bases for your decisions?

Do you go with the flow?

Many physical therapists choose to use ultrasound for their patients.

Patients often demand ultrasound and physicians often request ultrasound.

Ultrasound is often criticized for its poor evidence base despite widespread anecdotal reports of it's benefit.

Show your work

Here'e the easy way to demonstrate medical necessity (need) for ultrasound.

Create a simple checklist or chart template that you or your staff could fill out every time you or they select ultrasound.

Copy the template or checklist and make it part of the initial evaluation.

Have extra copies ready for those patients who request ultrasound mid-way through their treatment.

Use the checklist to describe the findings that indicate ultrasound is necessary.

Findings: Inflammation

For example, pulsed ultrasound may be used as an anti-inflammatory modality.

This chart checklist, filled out at the initial evaluation, may support the medical necessity (need) for ultrasound when used as an anti-inflammatory modality.

You may also create a template to check off the findings that support ultrasound's thermal effects for scar tissue, etc.

(YES/NO)	CONDITION	Dimensions
	Swelling
	Redness
	Tenderness
	Palpable heat
	Loss of Function

One or more of these conditions present, with the dimensions noted, could provide a basis for ultrasound.

Properly filled out initially, and at subsequent intervals for Progress Notes, this chart checklist is a decision-making tool that can help the therapist understand when certain interventions are, and are not, indicated.

As a physical therapy clinical manager it is your responsibility to provide these tools to your clinical staff to ensure a Medicare compliant chart.

When it is so easy to do - why not?

Good for the patient, the therapist and the Medicare auditor

A Medicare auditor could look at this checklist to clearly and quickly see why the physical therapist had charged for sessions of ultrasound in the physical therapy plan of care.

Some therapists have used this pen-and paper tool to explain to their patients when ultrasound, a modality with a strong placebo effect, may no longer be indicated.

Bottom line, simple tools that demonstrate your skilled physical therapy decisions and show the need for your valuable treatments are essential in today's clinical environment.

For more free tools, templates and tips on physical therapy Medicare compliance go to www.BulletproofPT.com . 

Predictive physical therapy: can questionnaires aide prognosis?

There is a new age of accountability (financial, regulatory and otherwise) in physical therapy.

Some examples...

Physical therapists are being asked to work and get paid based on their productivity rather than a fixed salary.

Medicare requires physical therapists to 'diagnose' their patients using objective, public-domain tools, like the OPTIMAL scale.

Now, physical therapists can predict whether patients will adhere to physical therapy after spine surgery. The test is called the Patient Activation Measure (PAM) questionnaire.

"Essentially, the test places patients on a continuum of activation ranging from those who don't see an active role on their part as necessary to those who are highly motivated to take an active role in their own health care." said lead author Richard L. Skolasky, Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

My professor in physical therapy school once told me that questionnaire data was 'soft' and that we needed 'real numbers' for good decision-making in physical therapy. In 1992, my professor called questionnaire data 'subjective' data.

Well, that was 1992 and this is 2008.

In 2008 and beyond, more of our physical therapy data will come from questionnaires. The good news is this... questionnaire data is good data.

The test that is destined to replace the OPTIMAL scale is the Activity Measure for Post Acute Care (AM-PAC). The AM-PAC produces good data.

Data is going to be necessary for physical therapists to demonstrate value to payers.

In 2006, the single largest purchaser of health care in the world, US Medicare, spent $3.06 billion on physical therapy.

Questionnaires can give us good data.

Good data can improve physical therapy accountability, diagnosis and prognosis.

Physical Therapy Diagnosis: Label or Process?

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

What is wrong with the patient?

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

Fine with me.

The ICF Browser has descriptors of the following:

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

...that affect human movement and function.

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

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

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


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


3. Decreased cervical rotation ROM, bilateral.
   

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

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

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

The descriptors for the above diagnosis are the following:

Body Function:

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

Body Structure

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

Activities

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

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

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

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

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

I do take measurements for each descriptor listed above.

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

'Anybody' includes the following...

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

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

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

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

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

When is a physical therapy diagnosis not a physical therapy diagnosis?

The most recent issue of The Orthopaedic Section's Physical Therapy Practice contains Developing a Physical Therapy Diagnosis for a Patient with Upper-extremity Paresthesia: A Resident's Case Problem by Trevor Lentz, Marty Huegel and Mark Bishop.

The authors state...

"the most likely source of the symptoms was cervical radiculopathy".

The problem is this 'physical therapy diagnosis' of cervical radiculopathy is that it is a medical diagnosis.

Medical doctors can get a little upset when they hear about physical therapists making medical diagnoses.

We can do better.

Instead, why not a functional diagnosis? Why not a physical therapy diagnosis that conforms to the International Classification of Functioning, Disability and Health (ICF) framework?

Using the ICF framework, measure activity limitations and impairments in body structure and function. Link activity limitations to impairments with the physical therapy diagnosis.

According to the article, the patient's symptoms "were limiting his sleep and work tolerance". These are the self-reported activity limitations.

The measured impairments included the following:

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test
• positive Upper Limb Tension Tests (A&B)
• limited cervical rotation bilateral

.
Why not a physical therapy diagnosis that simply states that the activity limitations were caused by the measured impairments?

"Limited sleep and work tolerance caused by

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test
• positive Upper Limb Tension Tests (A&B)
• limited cervical rotation bilateral

."

Why do we need a label?

The APTA House of Delegates policy statement on physical therapist diagnosis states...

"The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client."

Especially, why do we need a medical label that does not inform decision-making for physical therapists?

Ivory Tower Statistics

Here's the part where I'll get myself into trouble.

The authors diagnosed this patient based on a larger positive change in post-test probability for cervical radiculopathy than for carpal tunnel syndrome or thoracic outlet syndrome.

Yet when I read the 'exercise flow sheet' I find no treatments that would apply to a 'diagnosis' of cervical radiculopathy that might not also apply to a 'diagnosis' of Thoracic Outlet Syndrome.

So, what's the point?

Why encourage physical therapists to learn and study powerful statistics (likelihood ratios and nomograms) that don't direct daily clinical decision-making?

Use the list of findings to inform the decision-making process of what to include in the plan of care.

Assuming I measured the same impairments on the same patient couldn't I take the list of findings and design a plan of care that lead to the same exercise flow sheet?

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test - Manual Cervical Distraction
• positive Upper Limb Tension Tests (A&B)- Cervical Stretches
• limited cervical rotation bilateral - AROM

There, I didn't have to use any statistics to make a similar plan of care from the same list of findings.

Instead of making Physical Therapy Diagnosis more complicated, let's make it easier.

Unfortunately, the aforementioned HOD policy statement does not encourage improving the process. Instead, it sticks with outdated labels...

"In performing the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals."

Emphasize the process, not the label.

Disability does not need a medical diagnosis label.

Disability defies labels because people are more complicated, and more interesting, than pathology.

The Functional Classification of Neck Pain

Orthopedic physical therapists need to read this clinical practice guideline from the September 2008 issue of JOSPT.

In addition to using the International Classification of Functioning as the basis for clinical physical therapy decision-making the authors describe, in one place, many of the the tests and measures used to assess cervical impairments.

Especially useful is Table 4 which links subjective and evaluation data to interventions used during treatment.

Not only is Table 4 useful for clinical decision-making but could also be used to support 2 of the 3 criteria for Bulletproof Physical Therapy Charts and Notes

1. Medical Necessity for Physical Therapy
2. Skilled Physical Therapy (decision-making)

Written measurements of impairments are 'evidence' for a staff physical therapist to argue their case in the event of an unfavorable Medicare audit.

I recommend using high-quality, evidence-based guidelines such as this one to support not only excellent clinical decisions but also to support your Medicare compliance program.

For more information go to BulletproofPT.com.

Informed Physical Therapists Diagnose using the ICF

Informed physical therapists can make a break with 'old school' models and advance the discussion of physical therapy diagnosis by taking a look at these new APTA resources for the new International Classification of Functioning.

'Old School' models, many of which I have used, include most of the mechanistic models we learned in PT school and at 'Hilton University' (some of you may have gone to 'Marriott U' or 'Holiday Inn U').

To name a few...

NDT
PNF
McKenzie
Maitland
Mulligan
Paris
The Facet Joint
The Disc (...is a jelly doughnut)
Sacroiliac joint
McConnell taping

Now, with ICF, you can abandon models and just treat the patient.

This new paradigm (new to me since 2001) allows the physical therapist to measure characteristics of the patient that may impact function and apply treatments without regard to the mechanism.

Ah, freedom.

Freedom from justifying my treatments to other PTs, PTA's, patients or payers. If I get my patient better - who cares how I did it or what technique I used?

The power in the ICF model is that I can find freedom while a different PT or PTA can find meaning in a different way.

The ICF is a framework - not a blueprint.

I practice orthopedic PT but the ICF is equally appropriate for neuro PTs.

Use my templates and watch my videos to see how I use the ICF to inform PT orthopedic decision-making.

The Pragmatic Physical Therapist Avoids Models

I recommend the August 2008 Physical Therapy Journal for the Case Report titled

Process for Applying the International Classification of Functioning, Disability and Health Model to a Patient With Patellar Dislocation by Kevin Helgeson and A Russell Smith Jr

(subscription required)

I blogged about this article just two days ago

The patient was an active 23-year old female graduate student who wanted to return to hiking and running.

"She sustained the following... second-degree tear of the medial collateral ligament (MCL) of the right knee, with a lateral dislocation of the patella. She was referred for magnetic resonance imaging (MRI) of her right knee; the MRI was performed the following week. The MRI findings reported by the radiologist were “sprain of the medial collateral ligament with overlying edema and bone bruises of the posterior medial tibial plateau and of the lateral femoral condyle with a small knee joint effusion.”

What I found helpful was Helgeson and Smith's pragmatic approach to decision-making.

"The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was reevaluated through an assessment of the level of improvement of the patient’s primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

By pragmatic I mean the ability to change the plan of care based on the patient's response, measured at the level of the functional ability - in this case walking, hiking and squatting.

This pragmatic approach avoids the use of models - simplifications of human structure and function that are used as aids to decision-making.

The pragmatic approach relies on test data, functional ability, to make decisions.

I would have used the OPTIMAL test to measure functional ability.

The problem, as I see it, is that the use of test data to make decisions 'pigeonholes' physical therapists - that is, it forces them to make decisions that might be contrary to their favorite model or treatment technique.

Full disclosure: My favorite treatment technique for lower back pain is spinal stabilization.

When stabilization doesn't work, as indicated by my OPTIMAL score, I am forced to resort to other means, such as ultrasound or massage to treat the patient.

I don't like it - but I do it.

I wonder if other physical therapists are similarly vexed by using data?

Or, do you just stick with the model?

Physical Therapist uses the ICF model for Decision-Making

This is the first physical therapy article (that I have seen) since the APTA adopted the International Classification of Functioning (ICF) framework in June 2008 that uses the framework for decision-making.

I've used the framework when it was called the International Classification of Disability, Impairments and Handicaps (ICDIH) since late 2007, when I started writing this blog on Physical Therapy Diagnosis.

I've found the process liberating.

I feel more able to help my patients and at the same time I feel less personal responsibility if those patients fail to improve with physical therapy.

I just take the measurements (impairments and abilities).

I find the link - the Physical Therapy Diagnosis.

The treatments are more or less routine.

Back to the article...

This case report by Kevin Helgeson, PT, DHSc describes the treatment of a 23-year old girl with a recurrent patellar dislocation. The measurements and treatments described in the article are pretty routine: exercise, patellar gides, proprioceptive training, etc.

What I found interesting, in the 'Discussion' was the authors' comments on their decision-making process.

"An important aspect of this evaluation process in the ability to reevaluate the interrelationships within the ICF framework and decisions made throughout the course of treatment. The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was re-evaluated through an assessment of the level of improvement of the patient's primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

I can use this in my practice.

We use the OPTIMAL scale. We use the OPTIMAL to write Bulletproof PT Notes for Medicare compliance.

For example, I follow-up with a patient using the OPTIMAL.

They are not making progress with walking long distances. Their goal is 2/5 OPTIMAL. I record their current score, 4/5 (lower scores are better).

Based on their failure to improve, I decide to change their plan of care and try again.

I have just demonstrated skilled physical therapy using my decision-making. The OPTIMAL was my tool and the ICF was my framework.

You can see more examples of skilled physical therapy using the OPTIMAL (and other tests) within the ICF framework. It's all Medicare compliant. It's called Bulletproof Physical Therapy Charts and Notes.

The New Physical Therapy

"All models are wrong, but some are useful" begins the Wired Magazine article The End of Theory.

The article, by Chris Anderson (of The Long Tail fame), goes on to explain that in this current 'era of massively abundant data' scientists have become less reliant on the age old tradition of creating plausible models and testing hypotheses to refute or deny the model.

Instead, scientists can merely find correlations is massive data sets that have been, heretofore, unavailable for study and searching.

The power of sufficient data allows us to say "Correlation is enough" (Anderson).

Physical therapy has embraced this new thinking since 2002.

A manipulation decision rule was published in Spine magazine that laid out 5 predictor variables PT clinicians could test for: the presence of 3/5 variables implied that the patient was a good candidate for manipulation.

Anderson states that massively abundant data

"forces us to view data mathematically first and establish a context for it later."

The researchers first measured their physical therapy patients with dozens of 'traditional' physical therapy test and measures.

They then dumped the results of these measurements (some good, some bad) into a statistical 'hopper' and compared the results with the patients that got better.

Those tests that best predicted the patients that got better were the final predictor variables.

To paraphrase Anderson...

Who knows why patients get better? The point is that patients do get better and we can track and measure those patients with increasing accuracy.

"With enough data, the numbers speak for themselves"

Measurements are the key, however. Without measurements we cannot draw correlations.

Even Google could not search web pages if no one bothered to post their data.

Physical Therapy is not a 'Loss Leader'!

Some physical therapists think that refusing to accept 'loss leader' patients from Medicare Advantage plans will preserve physical therapists' pricing power.

A loss leader (in retail) is a product that is priced less than it's cost to produce. For example, Office Depot might advertise reams of copy paper at $30.99 for a case for a catalog order but the Office Depot web site has that same case for $44.99.

Office Depot will take an up-front loss in order to get you to use their catalog. They are counting on higher order volume (more items) with each catalog order.

The catalog represents a fixed-cost investment that Office Depot must amortize through higher order volume. The Office Depot web site is a relatively low-cost distribution channel that can be profitable on lower sales volumes.

What has this example got to do with physical therapy private practices?

Physical therapy private practices are fixed-cost investments for their owners. The owners only get paid back on these investments when revenues exceed costs.

Once your fixed costs (such as rent, salaries and utilities) are met you must still pay variable costs.

The variable cost to treat the Medicare Advantage patient is the cost of the ultrasound jelly you smoosh on her neck.

That's not very much.

Medicare Advantage rates are (still) higher than the one smoosh of ultrasound jelly.

You make more money than you lose when your reimbursement rates exceed your variable costs of keeping your doors open.

Cash is King

Physical therapy practice owners with full-time employees realize that pay day comes every two weeks whether or not cash is in the bank or not.

High-volume Medicare Advantage patients on your caseload prevents your employee physical therapists from sitting idle.

Yes, Medicare Advantage pays less than Medicare.

Yes, you will lower your profit margin (but you will survive).

Yes, you may ask your physical therapist employees to see more than one patient per hour.

No, you may not use aides to treat your patients (any patients - not just Medicare patients).

How, you may ask, should a struggling PT private practice owner survive?

My recommendation...?

Find out why your patient hurts.

Make the physical therapy diagnosis.

Treat the cause of their pain.

Treat the actual change in 'body structure and function' that has lead to their painful, dysfunctional state.

Tell them why they hurt and why they can't lift things up and why they can't walk more than a city block.

You must have the skills and the ability to measure deviations from normal that qualify your patient for physical therapy.

The growth in physical therapy over the last 30 years is a real trend that reflects real demand.

The value of physical therapy is undeniable.

The cost of physical therapy, however, is climbing and is subject to policy and political whims.

Physical therapy will not go away with changes in Medicare reimbursement rates.

Your physical therapy practice may go away, though.

Change is inevitable.

What will you do to create the future for you, your patients and your country?

To learn how to measure, diagnose and treat your patients better get this free tutorial.

Physical Therapy and the International Classification of Functioning and Disability

The Orthopedic Section of the APTA (and others, I assume) is attempting to link 'academic physical therapy' - typically viewed as too esoteric - with clinical physical therapy with a new model of describing common conditions seen in physical therapy patients.

The Orthopedic Section has a position statement on the following topic...

Use of the International Classification of Functioning and Disability (ICF) to Develop Evidence-Based Practice Guidelines for Treatment of Common Musculoskeletal Conditions

Joseph Godges, DPT, MA, OCS
Coordinator, ICF-Based Clinical Practice Guidelines

James J. Irrgang, PT, PhD, ATC
Orthopaedic Section President

The details are preliminary but the final goal is to guide physical therapy decision-making.

For example, how should a student physical therapist classify a patient with a physician's diagnosis of 'frozen shoulder? The ICF Shoulder Guidelines can instruct the new graduate how to perform the evaluation and diagnosis.

The ICF Lower Back Pain Guidelines are complicated and focus heavily on classification.

Physical Therapy Diagnosis can do much the same for lower back and lower quarter dysfunction using the SIMPLE system (details at www.SimpleScore.com).

If classification can guide daily treatment decisions then I encourage the new graduate and the 'old school' physical therapist to learn the ICF model.

The SIMPLE (Summary of Impairments of the Lumbar Spine and Extremities) system provides much the same in a more intuitive manner.

Link your measured impairments with the patients' self-reported functional limitations in order to improve your decision making.

More people will get 'more better' if you make it easy for them.

Physical therapy should be simple.

Regional interdependence may require a Physical Therapy Diagnosis

All physical therapists need to jump on this concept and get comfortable with treating 'the whole patient'.

The February Journal of Orthopedic and Sports Physical Therapy has this article...

Regional Interdependence: A Musculoskeletal Examination
Model Whose Time Has Come

This is a quote from the article...

'A best-practice model for managing patients with musculoskeletal complaints has yet to be identified.'

I disagree. The model exists but it has yet to be well-known. I have discussed the model extensively in this blog and further information is available at www.SimpleScore.com.

Further the authors go on to say the following...

"For example, do you routinely examine the hip region for impairments in patients you are treating for complaints of low back pain or knee pain? Likewise, are you examining the lumbar spine for impairments in patients with primary hip and knee complaints?"

As I noted in my last post, routine Physical Therapy Diagnosis will require many physical therapists to change long held, 'old school' practice patterns that allowed physical therapists to treat under a physician referral while abdicating decision-making authority to protocols, models or back to the physician.

Then, when we want that authority back, we find that others (chiropractors) have already taken the authority or that we never earned the authority.

PT Clinical Management

I got this e-mail from one of my clinic managers regarding our latest update to the Physician Re-certification Note (which, for Medicare purposes doubles as our Progress Note).

Eric and I regularly bounce ideas off of one another in order to improve the compliance of our Medicare treatments.

The point of this post is to emphasize that, in small PT practices, Medicare compliance is a two-way street. Everyone needs to be on board. Everyone needs to be committed.

Here is the e-mail exchange.

Real Time Clinical Management

From: Eric
Sent: Wednesday, February 27, 2008 6:23 PM
To: Tim Richardson PT
Subject: Re-certification note revision

Tim:

I see no problem with adding the Justification Statement for Physical Therapy. I don’t need the reference for this, but some examples sure would help.

Also, would you consider removing the goals met line? I could use an extra Impairment line and I will usually write (Met) on the line over (Goal) instead of checking off the box.

Eric



Eric,

Great question.

Once you've demonstrated Medical Necessity (in the POC) there is no further need in the daily Treatment Encounter notes to do so.

However, if you elect to continue the patient a 2nd 30-day period you should show, in the Progress Note, both Medical Necessity and the Expectation of Significant Improvement in a Predictable Timeframe (30 days).

If, for whatever reason, either of these criteria are not immediately obvious from the measurements, the OPTIMAL, the disability statements or from the Treatment Encounter Notes then you should, in the plainest language possible, state so in the Justification Statement.

For Example:

"Continue PT TIW x 4 weeks b/c diabetic frozen shoulder is taking longer than a 'regular' frozen shoulder."

or

"Continue PT TIW x 4 weeks. Patient motivated and ready to get back to PT after d/c from hospital for chemo"

or

"Continue PT TIW x 4 weeks. New Goals as follows..."
(note: new goals should progress patient to a higher level of function as demonstrated by serial (bi-monthly) OPTIMAL scale)

or

"All LTG met. Continue PT BIW x 2 weeks for instruction in maintenance program at fitness center"

or

"Continue PT TIW x 4 weeks. Patient very old (89 yo) and debilitated (100#) and Ther Ex is very slow."

Whatever, as long as the language makes sense and can be backed with measurements.

Remember, measurements and the interpretation of measurements is how you demonstrate Skilled Therapy (the only requirement for the daily Treatment Encounter Note).

Remember, once the patient hits the cap ($1,810.00 for 2008) there is the Automatic Exception based on Medical Necessity.

Don't use the diagnosis list only as your basis for an exception.

Remember your list of complexities and conditions that contribute to the Automatic Exception.

Bottom line, let the needs of your patient drive your therapy recommendations.

Call me if you have any questions.

I will ask Greg if he wants the 'Goals Met' sequence to be deleted.

Tim

The Orthopedic Surgeon Test

The Orthopedic Surgeon Test is a tongue-in-cheek name for a pragmatic approach to physical therapy clinical decision-making.

Whenever a physical therapist makes a clinical decision the test is to ask yourself the following question:

"What would the orthopedic surgeon think about this decision?"

So, if the physical therapist is asked a common clinical question like, for instance, the following:

"Do I put heat or ice on this hot, red, swollen and tender body part?"

Then, when you make the clinical decision to advise the patient to put ice on their inflamed body part you would certainly pass the Orthopedic Surgeon Test.

Physical therapists should extend this level of critical scrutiny to every clinical decision.

Perhaps I put too much pressure on or give too much credit to orthopedic surgeons in naming this test for them.

My assumption is that since their decisions ultimately direct the care for many of our orthopedic patients then they should get the glory (or the blame).

Orthopedic surgeons commonly base their decisions on independent measurements like x-rays. I use the term independent rather than 'objective'. Independent measurements imply that their interpretation will be the same for every observer.

Any decision that is based on a measurement will withstand scrutiny.

Physical therapists should also base their decisions on measurements.

Measurement eliminates argument.

A good example of clinical decision-making happened yesterday in the clinic. A patient asked me for a stretching exercise for her left hamstring - she said it was 'tight'.

This patient had a two-year old L4-5 microdiscectomy, complete motor palsy of the Flexor Hallucis and Digitorum Longii muscles (S1), sensory loss along the entire S1 dermatome and hamstring weakness (S1).

Additionally, her supine Straight Leg Raise (SLR) test measurements were the folowing:

Left 88 degrees
Right 85 degrees.

The video demonstration of this measurement technique can be found here.

Her left hamstring was longer than the right.

Perhaps because the hamstring muscle was weak she percieved 'tightness' and felt the urge to stretch.

Measurement, however, revealed that the hamstring was not 'tight'. The hamstring was not short and did not need stretching.

I re-measured the SLR and explained my findings to the patient. I advised her against stretching the hamstring muscle.

This young lady has a physical therapy plan of care that emphasizes stabilization training and avoidance of endrange movements like flexion and extension. Her understanding of physical therapy had led her to believe that stretching was a part of every patient treatment and thus would be a part of her treatment.

In fact, the measurements revealed that her mobility charcteristics could be labeled 'hypermobility' and her clinical presentation (which is more detailed than I have presented here) could be labeled as 'lumbar instability'.

Stretching, for this young lady, could be hazardous.

Based on my measurements I was comfortable in standing my ground and recommending against the patients stated desires. I did not provide her with the treatment that she thought she wanted.

If the orthopedic surgeon called and asked for hamstring stretching I believe I would make the same recommendations.

My clinical decision passed the Orthopedic Surgeon Test.