How physical therapists can quickly and simply demonstrate Medical Necessity and Skilled Physical Therapy.

1. Using Outcomes Questionnaires
to get to Medicare Compliance
How to Open and Manage a Private Practice Physical Therapy Clinic
Adam Geril PT, DPT
Adam Wood
Tim Richardson, PT
September 22, 2012
Orlando, Florida

2. Using Outcomes Questionnaires
to get to Medicare Compliance
• Describe the scope of the problem of documentation
• Introduce functional status questionnaires
• Link functional status to billing codes
• Describe 4 ways to link these together
• Video

4. Current Documentation Standards for
Outpatient CPT coding
1) Skilled Physical Therapy
Services
2) Medical Necessity or
Medically Necessary Services
3) Progress

5. Current Documentation Standards for
Outpatient CPT coding
American Physical Therapy Association sponsored webinar on Medicare Compliance ,
February 13, 2010
Daily note required for Therapeutic Exercise (CPT 97110)...
"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"
1

6. Current Documentation Standards for
Outpatient CPT coding
Physical therapy Medicare Compliance e-mail newsletter.
May 8th, 2012
Daily note required for a ‘typical’ physical therapy intervention...
“Treatment consists of manual therapy, 97140, to reduce
swelling and scar formation; followed by passive, active
assistive ROM exercise to improve ROM at the knee, 97110;
quad sets, SAQ, and SLR to promote the efficiency of the
quad contraction and promote quad control at the knee
joint, 97112; and then by working on sit to stand transfers
emphasizing knee flexion in sitting and equal weight
distribution in sit to stand and stand to sit, 97530.”
4

7. Case Scenario:
How to get from data to compliance

8. Current Documentation Standards for
Outpatient CPT coding

9. Current Documentation Standards for
Outpatient CPT coding
Belinda Holmes, Kerkering-Barberio, CPA, audit
September 25th, 2010 Medicare Compliance Seminar
Palmetto ,Florida
“I don’t know how you guys (physical therapists)
have any time to treat patients and make any
money!”

10. Current Documentation Standards for
Outpatient CPT coding
Medicare Benefit Policy Manual (280 pages)
Section 220 (44 pages)
Coverage of Outpatient Rehabilitation Therapy Services
(Physical Therapy, Occupational Therapy, and Speech-
Language Pathology Services) Under Medical Insurance
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/bp102c15.pdf

11. Current Documentation Standards for
Outpatient CPT coding
First Coast Service Options, Inc.
Local Coverage Determination
L29289 - Therapy and Rehabilitation
Services
http://medicare.fcso.com/coverage_find_l
cds_and_ncds/lcd_search.asp

12. Current Documentation Standards for
Outpatient CPT coding
220.3 – C
“Documentation Requirements for Therapy Services: Results of one of the following four
measurement instruments are recommended, but not required:
1) National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing
Association
2) Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)
3) Activity Measure – Post Acute Care (AM-PAC)
4) OPTIMAL by Cedaron through the American Physical Therapy Association
If results of one of the four instruments above is not recorded, the record shall contain instead the
following information ...”

13. Current Documentation Standards for
Outpatient CPT coding
1) Skilled Physical Therapy
Services
2) Medical Necessity or
Medically Necessary Services
3) Progress

15. Current Documentation Standards for
Outpatient CPT coding
Standardized Functional Status Measures
1) Baseline
2) Periodic
3) Outcome

16. Current Documentation Standards for
Outpatient CPT coding
1992 Questionnaire data is actively discouraged, it is too
“subjective”.
2006 Hart white paper. Many academics, policy-makers & therapists
feel that questionnaire data is too “soft”.
2007 Medicare “recommends” patient self-reports
2009 Jette study, 22% of PTs use “homegrown” patient self-report
measures.
2011 Functional data included in 33 quality measures for Medicare
Shared Savings Program (ACO)

17. Current Documentation Standards for
Outpatient CPT coding
Use of Standardized Outcome Measures in Physical Therapist
Practice: Perceptions and Applications
Jette et al, 2009
Only 48% of physical therapists used standardized measures of
outcome, but...
> 90% believed they enhanced communication with patients
> 90% believed they helped direct the Plan of Care

18. Current Documentation Standards for
Outpatient CPT coding
• Disorders of the Arm, Shoulder, Hand (DASH)
• Oswestry Disability Index (ODI)
• Activities Balance and Confidence Index (ABC)
• Lower Extremity Functional Scale (LEFS)
• Patient Specific Functional Scale (PSFS)
• Numeric Pain Rating Scale (NPRS)
• Global Rating of Change (GROC)
• Fear Avoidance Beliefs Questionnaire (FABQ)
• OPTIMAL Scale
• Focus On Therapeutic Outcomes (FOTO)

19. Various Therapy Metrics
Green – standardized self report questionnaires
Red – Performance measures
Blue – Clinical Decision Rules

20. Case Scenario:
How to get from data to compliance

21. Current Documentation Standards for
Outpatient CPT coding
1) Skilled Physical Therapy
Services
2) Medical Necessity or
Medically Necessary Services
3) Progress

22. Case Scenario:
How to get from data to compliance
Mary is a 65 year old retired schoolteacher with a gradual onset of activity-limiting lower
back pain. She has HTN 140/90, AODM (HbA1c 5.5%), cataracts, TKR right (2011), obesity
(BMI 31) and takes Xanax for depression. She is not physically active.
Diagnosis: Lower Back Pain
Chief Complaint: “My back hurts with lifting and transferring my Mom and I’m afraid to
kneel on my right knee because I’ve had a Total Knee Replacement”.
OPTIMAL score for kneeling 5/5 (unable)
OPTIMAL score for lifting 4/5 (much difficulty)
When prompted, she answers the following: “I should NOT do
activities which make my pain worse.”
Activity and Participation Limitation: “I’m caring for my mother
but I may have to admit her to a Skilled Nursing Facility
because I can’t physically help her anymore.”

23. Case Scenario:
How to get from data to compliance
Mary is a 65 year old retired schoolteacher with a gradual onset of activity-limiting lower
back pain. She has HTN 140/90, AODM (HbA1c 5.5%), cataracts, TKR right (2011), obesity
(BMI 31) and takes Xanax for depression. She is not physically active.
Diagnosis: Lower Back Pain
Chief Complaint: “My back hurts with lifting and transferring my Mom and I’m afraid to
kneel on my right knee because I’ve had a Total Knee Replacement”.
OPTIMAL score for kneeling 5/5 (unable)
OPTIMAL score for lifting 4/5 (much difficulty)
When prompted, she answers the following: “I should NOT do
activities which make my pain worse.”
Activity and Participation Limitation: “I’m caring for my mother
but I may have to admit her to a Skilled Nursing Facility
because I can’t physically help her anymore.”

24. Case Scenario:
How to get from data to compliance
“I’m afraid to
kneel on my right knee because I’ve had a Total Knee Replacement”.
OPTIMAL score for kneeling 5/5 (unable)
OPTIMAL score for lifting 4/5 (much difficulty)

25. Current Documentation Standards for
Outpatient CPT coding
1) Skilled Physical Therapy
Services
2) Medical Necessity or
Medically Necessary Services
3) Progress

26. Case Scenario:
How to get from data to compliance
Use of Quality Indicators in Physical Therapist Practice
Jette and Jewell, 2012
2,544 physical therapists surveyed...
Determine medication use 73%
Measured cardiovascular response to exercise 40%
Completed a standardized falls risk assessment 36%
Completed a standardized functional status measure 33%
Asked about tobacco use and advised to quit 21%
Measured and followed-up with referral for BP 11%
Measured standardized 10’ gait velocity 5.5%
Measure Body Mass Index (BMI) 3.6%
...physical therapists may not see themselves as... primary care providers. Patient management
strategies associated with these... services may be perceived as... burdensome.

27. Case Scenario:
How to get from data to compliance
Pertinent physical exam findings:
1) Stiffness in both hips (internal rotation ROM, usually measured prone with bubble
inclinometer.
2) Pendulous abdomen with low force producing capacity (usually measured supine or
sitting with a pressure biofeedback device).
3) Stiff, kyphotic thoracic spine (usually measured using
modified Schober's test of trunk forward bending
and sidebending).
4) Fear of movement, as noted. FABQ-physical activity = 14

28. Case Scenario:
How to get from data to compliance
Pertinent physical exam findings:
1) Stiffness in both hips - 97140
2) Pendulous abdomen with low force producing capacity – 97110, 97112
3) Stiff, kyphotic thoracic spine - 97140
4) Fear of movement, as noted - 97530

29. Case Scenario:
How to get from data to compliance
Drilling down from OPTIMAL Kneeling...
...can’t put on socks/shoes
...wears flip flops more often
...has stopped going to church as often
...feels less sociable
... is depressed

30. Case Scenario:
How to get from data to compliance
What are the “hard skills” of the physical therapist in 2012?
Assess functional status
Screening for pathology
Measuring vital signs

31. Case Scenario:
How to get from data to compliance

32. Case Scenario:
How to get from data to compliance
Symptom/Chief Complaint = LBP
Activity/Participation Limitation = unable Functional Status =
to fulfill role as caregiver, unable to live can’t lift/squat/kneel.
independently. Fear of movement.
Therapeutic Exercise 97110 Therapeutic Activities 97530
Manual Therapy 97140 Neuromuscular Reeducation 97112
Modalities/Traction

33. Case Scenario:
How to get from data to compliance
Paper-based:
1) Narrative notes (slide 3 & 4)
2) Task-oriented Flow Sheets (slide 29)
Electronic Medical Records (EMR):
3) Structured Data fields (slide 30 & 31)
4) Natural Language Processing (slide 32 & 33)
5) Video

34. Case Scenario:
How to get from data to compliance
Paper-based:
1) Narrative notes (slide 3 & 4)
2) Task-oriented Flow Sheets (slide 35)
Electronic Medical Records (EMR):
3) Structured Data fields (slide 36 & 37)
4) Natural Language Processing (slide 38 & 39)
5) Video

35. Case Scenario:
How to get from data to compliance
Task-oriented Flow Sheet
Kneeling on Foam unable unable Able to kneel 1’ on left with Left x 1’ Left x 1’
manual stabilization Right x 2’ Right x 2’
Functional Reach, 3-way x1’ forward x1’ x2’ x2’ x2’
x1’ left, too much trunk bend x1’ x2’ x2’ x2’
x1’right x1’ x2’ x2’ X2’
Single leg Support, eyes open x2’ x2’ x2’ x2’ x2’
Single leg Support, eyes closed x2’, contact guarding to minimize x2’, no contact guard x2’ x2’ x2’
postural sway
Manual therapy to improve hip flexion in Lateral right thigh x 5’ Lateral right thigh x 5’ Lumbar prone x 10’ Lateral right thigh x 5’ PROM hips in
standing Lumbar prone x 10’ Lumbar prone x 10’ PROM supine x 10’ Lumbar prone x 10’ supine x 10’
PROM hips in supine x 10’ PROM supine x 10’ PROM supine x 10’
Functional squat unable 10 reps, with breaks. Too much 10 reps, no stopping. Too much 20 reps, with breaks 20 reps, no
trunk flexion. Too much knee valgus. stopping
hip/knee valgus.
Four Square Stepping 4 x 1’ 4 x 1’ 4 x 1’ 4 x 1’, 2 sets 4 x 1’, 2 sets
Tandem walking 40’ 2 x 40’ 2 x 40’ 3 x 40’ 4 x 40’ with gaze 5 x 40’ with gaze
challenges challenges
Abdominal muscle pressure biofeedback Supine x 1’, tends to hold breath Supine x 1’ Supine x 2’ Supine x 2’ Supine x 2’
with device, supine and sitting Sitting x 1’, tends to hold breath Sitting x 1’, tends to hold breath Sitting x 2’, tends to hold breath Sitting x 2’ Sitting x 2’
Standing x 1’ Standing x 1’

36. Case Scenario:
How to get from data to compliance
Evaluation Visit 2 Visit 3 Visit 4 Discharge
Evaluation 97001 Schober’s test for spinal ROM Schober’s test
BP measure. Referred? BP BP BP BP
Fear Avoidance Beliefs (FABQ score)
Therapeutic Activities 97530 OPTIMAL Kneeling score OPTIMAL score
“Can’t kneel/squat to clean home or make the bed” (ICF
qualifiers and modifiers, 0-9)
“Can’t lift/transfer my husband”
(ICF qualifiers and modifiers, 0-9)
Therapeutic Exercise 97110 Hip Internal Rotation ROM score
Neuromuscular Reeducation 97112 Pressure biofeedback score of abdominal force
producing capacity, sitting/supine
Manual Therapy 97140 Knee AROM & PROM
Modalities/Traction

37. Case Scenario:
How to get from data to compliance
Visit #1: ““I’m afraid to kneel on my right knee because I’ve had
a Total Knee Replacement”.
OPTIMAL score for kneeling 5/5 (unable)
OPTIMAL score for lifting 4/5 (much difficulty)
Visit #2: “97112 (x2) pressure biofeedback to improve
abdominal force-generating capacity to facilitate
lifting/transferring her husband.”
Visit #3: “97530 (x2) challenging/educating Mary’s fearful
attitudes about kneeling/squatting. 97110 performing simple
non-painful knee/hip flexion tasks that she has previously
avoided.” 6

38. Case Scenario:
How to get from data to compliance
Natural Language Processing

39. Case Scenario:
How to get from data to compliance
Natural Language Processing

40. Current Documentation Standards for
Outpatient CPT coding
1) Skilled Physical Therapy
Services
2) Medical Necessity or
Medically Necessary Services
3) Progress

41. Case Scenario:
How to get from data to compliance
Video documentation

42. Case Scenario:
How to get from data to compliance
“As required by the Middle Class Tax Relief Jobs Creation Act of 2012, CMS proposes to
implement a claims-based data collection process to gather data about patient function for
patients receiving outpatient physical, occupational, and speech therapy services.
Therapists would be required to report new codes and modifiers on the claim form that
reflect a patient’s functional limitations and goals at initial evaluation, periodically
throughout care and at discharge.
This data is for informational purposes and is not proposed to be linked to reimbursement.
This reporting system is proposed to be implemented on January 1, 2013. Claims will be
processed during the first 6 months until July 1, 2013 regardless of the inclusion of the
functional limitation codes.
Beginning July 1, 2013 all claims must include functional limitation codes to be paid by
Medicare.”

43. Case Scenario:
How to get from data to compliance
• Describe 5 ways to link functional status to billing codes
• Important because functional status is an important, if
overlooked, aspect of the patient experience in healthcare.
• Narrative, especially handwritten, is inadequate and
embarrassing in the 21st century to reflect physical
therapists’ skill and abilities.

44. Thank You!
How to Open and Manage a Private Practice Physical Therapy Clinic
Adam Geril PT, DPT
Adam Wood
Tim Richardson, PT
September 22, 2012
Orlando, Florida