Monday, October 29, 2007
The day the article ran I got an e-mail from a former Vice President of Operations at HealthSouth who took issue with my analysis.
He said it was incomplete.
What I couldn't know from studying the 2007 HealthSouth Annual Report was that the firm couldn't hold onto talented, ethical therapists. He said physical therapists were leaving in droves and the ones that remained couldn't compete with the smart, tough local independent physical therapists.
He said he had opened his own clinic and was competing successfully against his former employer.
He had become one of us.
Thursday, October 25, 2007
The Disablement Model is a great way for physical therapists and physical therapist students to begin thinking about physical therapy diagnosis.
My undergraduate physical therapy education at the University of Florida in 1992 did not have any mention of Nagi or WHO (World Health Organization) or the process that leads from tissue pathology to physical handicaps.
Physical therapist assistants, however, that graduate in 2008 will have had 4 semesters of information that is permeated with information on the disablement model and they should be comfortable with practice patterns that incorporate ‘disablement thinking’.
Disablement thinking was a concept in 1992 but disablement thinking should be common practice in 2008. If physical therapists are not practicing with disablement concepts firmly in mind then it is because there are not sufficient tools in place to bridge the gap between concept and practice. I have designed the SIMPLE system to be one of those tools.
The SIMPLE system is a decision-making tool for physical therapists to decide on a diagnosis, to decide on goals and to decide on physical therapy interventions.
Pathology doesn’t do a good job of guiding the decision-making process for the physical therapist (see Sandstrom RW in PT Journal).
The Nagi Model
The SIMPLE system adheres to the Nagi disablement model and to the Guide to Physical Therapist Practice regarding the relationship among disability, functional limitations and impairments.
The SIMPLE system also adheres to the recommendations in the latest updates to the Medicare Benefit Policy Manuals and in the state-specific Local Coverage Determination
(here is the link for Florida) for the purpose of creating compliant physical therapy plans of care and for physical therapy goal setting.
Begin with the physical therapy diagnosis
The diagnosis is the link between the measured impairments and the measured functional limitations. The SIMPLE system cannot make the diagnosis – only the physical therapist can make the diagnosis. The SIMPLE system automates the charting and the documentation once the physical therapist makes the diagnosis.
Physical therapists’ time is far too costly and their expertise too valuable to spend in their back office making up new goals for certain high-volume diagnoses.
Physical therapists need an easy way to put on paper the skilled stuff they do with patients. If a physical therapist doesn’t have to worry about “What do I have to write down to pass a Medicare audit?” then they can spend more time with their patient doing the skilled care that gets people better.
Skilled care is not complicated but it is hard work. Medicare documentation is complicated but it doesn’t need to be hard work. Not if you use the SIMPLE system.
It’s a simple process.
It’s a simple system.
Bottom line, it’s better physical therapy.
Tim Richardson, PT
Tuesday, October 23, 2007
Physical therapy diagnosis helps the doctor.
The physical therapy diagnosis helps the doctor because the diagnosis is stated in universally understood terms (eg: range-of-motion and strength). The physical therapy diagnosis avoids medical diagnosis (eg: tendonitis) and so the physician is not threatened or offended.
Diagnosis systems which invent specific terms to describe commonly encountered clinical phenomenon are too complex for the busy physician or the distracted patient to try to learn.
Physical therapy diagnosis helps the new graduate physical therapist.
Simple physical therapy diagnoses (eg: shortened hamstring muscle) encourage new graduates and those older graduates who may not have taken advanced orthopedic physical therapy coursework to make their initial diagnosis.
As the new graduate begins to gain confidence in their diagnostic skills they will naturally progress to recognized patterns of impairments that tend to occur together. This pattern recognition will make the diagnostic process faster and easier.
Automate the decision process
Making a physical therapy diagnosis at the initial evaluation improves the decision-making process by automating the goal setting and the choice of interventions. Diagnostic decisions flow automatically from a limited number of options that apply to measured impairments, for example: a shortened hamstring muscle can be treated with the following interventions:
- Manual Therapy (97140), massage or myofascial release.
- Therapeutic Exercise (97110): passive or active range-of-motion, stretching exercises or progressive resistance exercise.
- Neuromuscular Reeducation (97112) to lengthen the hamstring with a stable lumbar spine.
The goal would flow directly from the measurements. For instance, if the right hamstring has 70 degrees straight leg raise and the left hamstring has 90 degrees straight leg raise then the goal would be written as follows:
Increase right hamstring straight leg raise from 70 to 90 degrees.
For example, a patient comes in with heel pain.
You measure the fastest, easiest metric for the foot: Standing Heel Raise. You obtain the following values:
Standing Heel Raise: 6cm Right
Standing heel raise is a standardized measurement that purports to describe the strength of the posterior leg muscles and the range of motion of the ankle joint.
Our measurement indicates that the posterior leg is weak. The initial goal of therapy should be to strengthen the weak muscle.
The physical therapist would set the first long term goal of therapy as follows:
Strengthen the right Standing Calf Raise from 6cm to 10cm.
Ten centimeters is the ‘cut score’ that defines a treatment success or a treatment failure. Cut scores can be determined empirically or statistically (See Risk and Physical Therapy by Newman and Allison).
The physical therapist selects the appropriate intervention to meet the long-term goal. In this example, therapeutic exercise is the most appropriate intervention for calf strengthening.
The documented description of the intervention would read as follows:
“Therapeutic exercise for strengthening the right calf muscle.”
The description of the intervention would need to be noted in the plan of care but not in each subsequent note (see Medicare Benefit Policy Manual Transmittal 63).
The diagnosis is predicated on good measurement. With good measurement and good diagnosis the physical therapist can do the following:
- Set goals
- Select interventions
- Determine progress by periodic re-assessments
- Make predictions about the future
- Give a discharge diagnosis
Automating the decision process with good measurement and good diagnosis allows the physical therapist to personally step back from the patient outcome. The physical therapist can identify and measure the impairment and link the impairment to the functional limitation.
The process of selecting the interventions that will best address the impairments and the functional limitations becomes a negotiated interaction between the physical therapist and the patient.
Physical therapy diagnosis de-emphasizes the importance of modalities. I’ve never seen a muscle get stronger with ultrasound.
A Final Example
Another example should help make my point.
My last patient this morning had the following diagnoses:
- Weak bilateral hip internal and external rotator muscles
- Weak bilateral hip abductors
- Weak left hip flexor muscle
- Short left hamstring muscle
- Stiff bilateral trunk rotation range-of-motion
I made these diagnoses with precise measurements. I compared the measurements to a ‘cut score’ from a large sample of patients. Any value that failed to reach the cut score for range-of-motion or strength was ‘weak’ or ‘stiff’ or ‘short’.
The point is that this patient had many physical impairments. Obviously she also had profound disabilities and severe pain. No amount of ultrasounds or hot packs will ever improve these impairments.
A physical therapy plan of care that is built around modalities will undermine the urgency of improving the true cause of the pain and the disablement: impairments in strength and range-of-motion.
Wednesday, October 17, 2007
If you don’t use the group code (CPT 97150) in outpatient physical therapy billing and you dovetail treatments (every :30 minutes) then your company’s behavior sends a message to your employees
The message is this:
We don’t believe our charts and documentation are sufficiently well-written to survive a Medicare (Part B) audit. Also, we aren’t sophisticated or intelligent enough to learn and understand how to correctly code and document the group code.
Fly Below the Radar
Your employees will correctly perceive your corporate compliance strategy is ‘flying below the radar’ – don’t bill it so we don’t get caught. The unspoken secret is that there may be other areas where your Medicare compliance is less than optimum. You would rather give up group code revenue rather than invite suspicion on your other, ‘less risky’ coding patterns.
Rather than give up any revenue why not just learn the appropriate billing strategy and the appropriate way to chart the visit?
The reader can look to the Center for Medicare and Medicaid Services (CMS) Part B PT/OT group coding scenarios at this link: CMS Group Billing Scenarios.
This link has Center for Medicare and Medicaid services official interpretation of many physical and occupational therapy treatment scenarios.
Medicare vs. Everyone Else
What if you bill group code to Medicare patients but not to any other patients?
The Common Procedural Terminology (CPT) codes, created and defined by the American Medical Association (AMA), are not the exclusive province of Medicare. Therefore, you should apply the group code without regard to who pays for the physical therapy service.
The AMA is a professional association that generates revenue from creating, designing and promulgating CPT codes. They don't enforce the codes.
A legal issue probably arises in the insurance contracts that each physical therapist signs with each (non-Medicare) insurance company. The contract may contain language that states the eligible beneficiaries are not to be discriminated from any other patients.
For example, one of my contracts with an insurance company states the following:
"Responsibilities of the Provider:
1) Provide Medically Necessary Health Services to Covered Individuals in a manner similar and within the same time availability in which health care provider provides such services to any other individual and XYZ Co. Provider will not discriminate or differentiate against Covered individuals"
In other words, neither the AMA, the American Physical Therapy Association (APTA) or CMS will care if you treat Medicare patients better than non-Medicare patients. That is, if you are compliant with Medicare ‘rules’ then there are no grounds for CMS to take action.
You may, however, be in violation of your contractual obligations to the insurance company. You may also be in violation of the APTA Code of Ethics.
Principle 2 states the following:
“A physical therapist shall act in a trustworthy manner towards patients and in all other aspects of physical therapy practice”
Principle 3 states this:
“A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients”
Many of my friends and peers, physical therapists in private practice, have admitted to under-billing the group code because of its perceived ‘red flag’ status.
I think this is a mistake. Know the rules. Follow the rules.
Knowledge is power. Use it.
Tim Richardson, PT
Tuesday, October 16, 2007
I was more eager than I was experienced when, in 2006, I bought controlling interest of my physical therapy clinics (3 of them) from our founding partners (2 of them).
After closing the sale the three of us were sitting around a large wooden conference table having a pleasant chat when one of the founders made this comment:
‘Our charts would never stand up to a Medicare audit’.
I can recall the frantic desire to find and tear into pieces my check and all the closing documents that we had just signed.
From that moment on I dedicated myself to developing a system that could reliably train and motivate my seven physical therapists and physical therapist assistants to quickly and completely create a Medicare compliant plan of care, daily note and discharge.
Most importantly, the system had to be based on the patient’s needs so that the therapist was allowed to do what the therapist does best: care for the patient.
I wanted a system that allowed the PT and the PTA to work together, using the clinical decision-making of the PT and the clinical judgment of the PTA5. I also felt the system needed to be diagnosis-driven from the start. A physical therapy diagnosis, that is.
I want to be able to share this system with my peers who own or manage their physical therapy clinics and who might not have access to a sophisticated corporate compliance department.
What I hope to present here is a standard process of measurement, diagnosis, goal setting and selection of interventions that displays both a rigorous thought process and an intuitive understanding of Medicare (and of the common needs of all third party payers, both commercial and federal).
Finally, the system should to both the experienced clinician and to the new graduate.
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Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.
Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.
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