Every day I answer questions from older Americans about their physical therapy.
"Will I run out of Medicare physical therapy benefits?"
"What will happen to me - will I have to go into a nursing home?"
Medicare provides physical therapy treatment up to $1,810 in billed charges for the purpose of preventing a loss of independance in older Americans.
Americans living at home, cared for by their loved ones, consume fewer healthcare dollars than Americans living in institutions.
Medicare pays for much of the institutional care in the United States.
Today, I treated Sarah, an 86-year old lady with arthritis.
Sarah is legally blind and cannot walk far because of pain in her back and legs due to a condition called spinal stenosis.
Sarah's husband died a few years ago and now she is alone.
Sarah can clean her home and care for herself with minor accomodations - she rides the handy bus to church, groceries and physical therapy.
She doesn't go out much but she lives in a trailer park where neighbors are close by.
But, Sarah is not far from needing more help.
She has been in physical therapy for her spinal stenosis for a month now and we have gotten her back to walking and single-stair climbing (we live in Florida).
Sarah is much more comfortablenow moving around and doing light lifting.
Friday, November 7th is Sarah's projected discharge date and she is worried that physical therapy will not continue.
She is afraid that she will decline without therapy and require more help to live alone.
Soon, she believes, she will need to move out of her trailer and into a nursing home.
Sarah believes physical therapy can help prevent this decline.
So do I.
Medicare depends on me to prevent Sarah from losing her independance and going to live in a nursing home. But, for that, I have to make decisions that expose me to the threat of a Medicare audit if it is determined that I gave Sarah 'too much' physical therapy.
What do I do?
I must show that I can help Sarah, that Sarah needs my help and that only a physical therapist, such as I, could help Sarah.
For that I need help. I need two tools. Both are free tools.
The first tool is the OPTIMAL.
I use the OPTIMAL to show that Sarah needs physical therapy.
The OPTIMAL also shows that Sarah can now walk further and move around better than she did one month ago. It shows she makes progress in physcal therapy.
But, I also need one more tool. I need to append a '-kx modifier' to my physical therapy charges that I send to Medicare.
I want to show any Medicare auditor that my decision to append that modifier is based on results, not just a one-time event or measurement.
So, I graph my OPTIMAL scores.
Here is the graph template.
What happens to Sarah?
Friday I take my follow-up measurements.
Sarah's need and progress is evident.
My skill and decisions are well-documented with the graph template.
This time, I think she will qualify for the extra month of physical therapy.