Does an X-ray demonstrate medical necessity for physical therapy?
...or does an axial CT myelogram?
These images are examples that have in common a clear pathology that many patients and physical therapists confuse with medical necessity for physical therapy.
Right now (November 17th 2008) I have several physical therapy patients who have exceeded their $1,810 Medicare benefit and are asking me for continued physical therapy services in my outpatient clinic.
Many of these patients have chronic conditions such as the following:
- degenerative spinal stenosis
- massive rotator cuff tears
- knee osteoarthritis
These conditions often require extended courses of physical therapy or multiple episodes of physical therapy in the course of a calendar year.
In my clinic, the $1,810 Medicare cap is usually reached by 16-18 visits.
It would not be unusual for degenerative spinal stenosis to take 20 visits. I'm pretty sure my experience is typical.
Who needs PT?
For an exception to the Medicare cap the physical therapist would have to show three criteria:
- Need
- Progress
- Skill
The above X-ray and CT myelogram show physical findings based on anatomy.
Physical therapists should show physical findings based on function.
Diagnosis: Process or Label?
An epiphany in own my practice has been the use of disablement models: most recently the International Classification of Function (ICF Model) that describes the link between Body Structure and Function and Activity Limitations.
The ICF classification framework is to physical therapists what the ICD-9 diagnostic labels are to physicians.
Note the ICF model describes any health condition - for instance, your patient with degenerative spinal stenosis who has 'run out' of Medicare physical therapy benefits but asks you to append the -KX modifier to continue their care.What do you do?
Do you ask the doctor for another script?
Perhaps you consider using another diagnosis from the old 'diagnosis list' from 2006.
Don't.
The Therapy Cap
The purpose of the therapy cap is to cut costs without limiting patient access to necessary care.
There is a large POPTs in my town that automatically cuts off therapy to every patient approaching the $1,810 Medicare Cap - regardless of need or progress.
They perceive that, as a POPTs, they are in the Medicare audit crosshairs and they refuse to add 'risk' to their caseload by appending the -KX modifier.
They are limiting care to their patients.
The Caps Work
Data for this table comes from the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2) Task Order - Utilization Report.
| Outpatient Physical Therapy | |||
| 2004 | 2006 | Per cent change | |
| Mean dollars paid per user | $864 | $788.06 | -8.8% |
| Mean dollars paid per episode | $748 | $682 | -8.9% |
| Standard deviation paid per episode | $1,047 | $782 | -25.4% |
"The Balanced Budget Act of 1997 enacted financial limitations (therapy caps) on outpatient physical therapy (PT) and speech-language pathology (SLP) combined... In 2006 the Automatic Exceptions Process to the caps began, enacted by the Deficit Reduction Act of 2005." (OTAPS 2)
The result of the caps has been the observed decrease in per user and per episode dollars paid.
Read the full blog entry here.
Note that cost reductions occurred from 2004 to 2006.
There was no cap in 2004. The cap exceptions process began in 2006.
The Caps work - so, work with the Caps
Get better at showing need.
Show that your patients have Activity Limitations using a functional scale.
I recommend the OPTIMAL scale (free) or the AM-PAC (small $$).
Show Progress.
I've designed a neat pen-and-paper graph that easily and quickly shows functional progress over 1, 2 or 3 months.
No more discharges after 20 visits whether the patient is better or not.
Now, patients come back to me because they know I can 'go to bat' for them.
If they are getting better I can prove it.
Get a copy of the Functional Progress Graph here.
Make skilled decisions.
Use the ICF model to link impairments in Body Structure and Function with the measured Activity Limitations.
The link is your Physical Therapist's Diagnosis.
What do YOU need to go to bat for your patients?
Not fancy x-rays or 'alphabet soup' imaging.
Get better at describing your own skills using simple tools.
Get the free tools I've described in this post.
Also, get a free tutorial called Bulletproof PT to learn more.
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