Medicare‌ ‌Regulation,‌ ‌Documentation,‌ ‌and‌ ‌Finance

Medicare‌ ‌Regulation,‌ ‌Documentation,‌ ‌and‌ ‌Finance

Nick Blonksi, UNM DPT ’21

 

Medicare is a federal health insurance program that contains four parts (A-D) and is accessible for individuals that are 65 years or older, younger individuals with disabilities, and people with end-stage renal disease, and ALS.1 Each part of Medicare’s insurance plan provides different types of coverage for members. Part A covers “hospital insurance” meaning inpatient hospital stays, care in skilled nursing facilities, hospice care, and home healthcare agencies.1-2 Part B covers “medical insurance” meaning it covers outpatient care, medical supplies, some doctor services, and preventative services.1 Part C and Part D are both optional programs for Medicare member. Part C is considered an advatage plan and works by having the patients covered through a different company that Medicare pays, regulations are still through Medicare still.2 Part D covers prescription drugs for the patient.2 During the 2018 calander year 18% of the population in the United States was covered by Medicare.3 With nearly a fifth of the population having Medicare and other private payers following Medicare rules and regulations it is important for all health care providers to be confident navigating the world of Medicare. 

Home Health care is covered by Medicare and Medicaid and falls under Part A of Medicare coverage. To be covered for Home Health Care criteria must be met to prove that the patient is homebound. The two criteria are that they must have an inability to leave the home and if they tried to leave the home it would require a lot of effort and be taxing to accomplish.4 On top of these criteria they also need to be under the care of a physician and the plan of care must be approved by the physician. As physical therapists many roles are expected in a home health care environment. Physical therapists use an outcome measure called the “OASIS” to assess the patient on the initial evaluation. This outcome measure looks at the patient’s overall health through a systemic approach, while also looking at the patient’s functional abilities.4 In January of 2020 Patient-Driven Grouping Model (PDGM) became the new payment model for home health and aims to use clinical characteristics and patient information to put the patients into 432 case mix payment groups.5 The PDGM utilizes 30 day periods and requires an updated OASIS at 60 days or when there is a significant change in the patient’s status. The PDGM only is used for payment in the patient has visits that are above Low-Utilization Payment Adjustments (LUPA) for the specific patient case-mix group. If the patients number of visits are below the LUPA the visits are billed per-visit.5 All home health agencies also participate in quality assurance performance improvement (QAPI) that provides insurance companies, the state, and the agency itself to compare the agency to national norms and know what they are doing well and what they need to improve on.4 Other measures that are used in home health agencies to monitor their effectiveness, and outcomes are the CASPER, 5 star, and PEPPER tools.4

In an acute care inpatient setting the Center for Medicare and Medicaid Services (CMS) lists rehabilitation as an option service. For inpatient acute care hospital settings that do provide rehabilitation and follow the CMS regulation that before treatment a plan of care needs to be put in place that includes diagnosis, type, amount, frequency, and duration of rehabilitation services. It is also required in the plan of care to have the anticipated goals for the patient. In acute care patients are put into Diagnosis Related Groups (DRG), based on what DRG the patient is in Medicare part A will put together a bundled payment plan that is given to the hospital.6 However DRG alone do not make up the reimbursment given to the hospital. Reimbursment is calculated by using a case mix index (CMI) that takes into account the DRG and severity of the illness, while also considered the patients co-morbidities and the resources that are required to treat the patient.2 A patient with a higher weighted CMI the reimbursment will be higher that is given to the hospital to cover the patients stay. If however the patient develops a hospital born secondary condition, such as a pressure ulcer, no new money will be provided and the hospital will have to eat the extra cost if it exceeds the reimbursment given through the DRG and CMI. With the reimbursment the hospital then can provide whatever care is needed to the patient, this includes all the follow-up care given to that patient. Through the bundle payment model PT alone does not generate money for the hospital from services provided, however as a valuable member of the treatment team can help patients discharge faster, decrease readmission through proper discharge, and increase patient satisfaction. It also important to remember that it matters where the patient is seen within the hospital as emergency rooms, and observational status patients are billed as outpatient and fall under Medicare Part B coverage.7 

Inpatient rehabilitation facilities (IRF) also follow along with acute care in having a predetermined payment amount through a bundle payment. This is determined by grouping patient cases into rehabilitation impairment categories, based off of diagnoses. Once in these groups patients are further grouped into cognition and functional groups and comorbidities are considered to place patients into four tiers.8 Based on what tier the patient is in the payment for that case increases or decreases. Other criteria considered for reimbursement is geographical wages, number of low income patients seen, and if there is resident training at the facility. IRFs also have to have 60% of their patients fall under 13 categories of diagnoses ranging from strokes and other significant neurological conditions to fractures of the femur.8 

In IRF the patient’s individualized plan of care must be completed by a physician with involvement from all team members that are part of the patients care team. The plan of care needs to be completed within 4 days of admission. IRF also requires the care team to have an initial team meeting within one week of admission and most meetings then occur weekly throughout the length of stay.8 Within IRF physicians are required to order all therapy services. For physical therapists the CARE tool is used to help support documentation and show the patient’s need for intensive rehabilitation by scoring the patient’s functional abilities on 17 functional activities. The Care Tool can be completed over a 3 day period at admission and at discharge for the patient.8 Group therapy services can be provided to the patient along with concurrent therapy when the therapist finds this appropriate. Regulations in IRF for group therapies are no more than 4 patients to 1 PT or 1 PTA at a time, and all the patients need to be doing the same exercises. Also patients should have no more than 25% of the patients therapy sessions can be group therapy.9

Outpatient physical therapy can fall under two different structural models. If the outpatient clinic is hospital affiliated it is considered a comprehensive outpatient rehabilitation facility (CORF) and requires a physician referral.9 The other model is a Private PT clinic that does not require a physician referral for Medicare. For both outpatient models Medicare pays through Part B and both require a certified POC.10 Outpatient clinics are paid by the services they provide through relative value units (RVUs) for the time spent on different current procedual codes (CPT) that outline different types of treatment interventions. Because of this outpatient clinics require the direct supervision of PTAs and eliminate the ability to bill for student lead services as they are not skilled.9 As an outpatient physical therapy clinic a plan of care must be written by the physical therapist and signed by a physician within 30 days of the initial evaluation to be certified with Medicare.10 The POC that is written must contain a PT diagnosis, long term treatment goals, type of treatment, amount, frequency and duration of PT services. The certified POC is valid for 90 days from evaluation unless the POC needs to be modified. Once either condition is met a new POC needs to be recertified.10 Within a POC a progress report is written to provide justification for treatment every 10th visit by the physical therapist. Lastly, Medicare requires a daily treatment note to be written to provide evidence of skilled treatment.10 For each patient a therapy cap of $2040 is alotted for the combination of PT and speech therapy services over a year. If a patient requires more service then is possible under $2040 justification is required from the therapist to show the medical necessity.

Overall physical therapy is typically covered through either Part A or Part B of Medicare. Home healthcare agencies, IRF, and skilled nursing facilities all fall under Part A of Medicare and are paid through a bundle payment that is based on the patients diagnosis, comorbidities, and functional impairments.9 This differs slightly from Inpatient Acute Care Hospitals, even though they fall under Part A, since only the diagnosis & comorbidities are considered for the bundle payment.9 CORF and Private PT Outpatient are covered by Part B of Medicare and are paided for by the services that are provided to the patient. Outpatient clinics have extra regulations to ensure that the services being provided are skilled. One is that supervision of PTAs needs to be direct instead of general like all other settings, and another is the inability to bill for services provided by PT techs and students.9-10 Medicare regulations, documentation, and billing are important to understand as they set the bar for insurances and account for nearly one fifth of insurance coverage in the United States.3

References:

1. “What’s Medicare?” Medicare, www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare. Retrieved 06/21/2020

2. Vallejo, Rose. “Insurance 101 & Introduction to Medicare.” PT 680-Administration and Supervision for Physical Therapists. PT 680-Administration and Supervision for Physical Therapists, 1 May 2020, Albuquerque, University of New Mexico Division of Physical Therapy.

3. “MDCR ENROLL AB 2 Total Medicare Enrollment: Total, Original Medicare, and Medicare Advantage and Other Health Plan Enrollment and Resident Population, by Area of Residence, Calendar Year 2018.” Centers for Medicare & Medicaid Services, www.cms.gov/files/document/2018-mdcr-enroll-ab-2.pdf. Retrieved 06/21/2020

4. Hastings, Lucas. “Home Health: Implications for the PT.” PT 680-Administration and Supervision for Physical Therapists. PT 680-Administration and Supervision for Physical Therapists, 9 June 2020, Albuquerque, University of New Mexico Division of Physical Therapy.

 5. “Centers for Medicare & Medicaid Services Patient-Driven Groupings Model.” Centers for Medicare & Medicaid Services, Abt Associates, www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf. Retrieved 06/21/2020

6. “DRG Classifications and Software.” Centers for Medicare & Medicaid Services, 5 Nov. 2020, 6:09 PM, www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software. Retrieved 06/21/2020

7. Jarnagin, Forest. “Regulatory Issues in Acute Care and Supervision and Leadership .” PT 680-Administration and Supervision for Physical Therapists. PT 680-Administration and Supervision for Physical Therapists, 16 June 2020, Albuquerque, University of New Mexico Division of Physical Therapy.

8. Vallejo, Rose. “Inpatient Rehabilitation Facility (IRF) Medicare Regulation” PT 680-Administration and Supervision for Physical Therapists. PT 680-Administration and Supervision for Physical Therapists, 11 June 2020, Albuquerque, University of New Mexico Division of Physical Therapy.

9. Vallejo, Rose. “Outpatient Physical Therapy Private Practice Clinic Park B.” PT 680-Administration and Supervision for Physical Therapists. PT 680-Administration and Supervision for Physical Therapists, 18 June 2020, Albuquerque, University of New Mexico Division of Physical Therapy.

10. Vallejo, Rose. “Medicare – Part B Documentation.” PT 680-Administration and Supervision for Physical Therapists. PT 680-Administration and Supervision for Physical Therapists, 18 June 2020, Albuquerque, University of New Mexico Division of Physical Therapy.

Dec 2017 Newsletter: What to Expect When Starting PT School

December, 2017 Newsletter

What to Expect When Starting PT School

Lisa Peterkin, SPT

Everyone goes into their physical therapy program knowing that it’ll be hard work.  Knowing that they just spent the last 4 (probably a lot more) years preparing for admission and another 3 years of classes, studying, and exams. But no matter how much you prepare mentally and academically, you never really know what you’re getting yourself into.

Like many of my classmates, I took two years off in between graduating from college and starting graduate school. However, unlike many of those students, I continued to take classes during that period to complete any missing prerequisites.   I was still in student mode and in the studying mindset when I began graduate school.

As we prepared for our first real exam a month into our first semester, many students feared they had “forgotten how to study” and were very nervous about the quantity of information we needed to know.

Some people passed with flying colors while those who had “forgotten” their regular study habits received a loud wake up call that they would need to rediscover those old study habits in order to pass.  With the emphasis on quizes and exams during the first year, everyone needs to quickly “remember” how to diligently study.

Right before Thanksgiving break, we had our first heavy round of tests with 6 exams within two weeks. Everyone studied harder for our anatomy quizzes than we did for any final we had taken in college.

We looked at the second years, jealous that they were past the madness and stress of first year, wishing we could fast forward in time. And we continued to look at the second years in jealousy for the next 8 months. Little did we know, it wouldn’t get any easier.

After coming back from our first orthopedic rotation over the summer, we were excited
to enter a less demanding year.  We were also happy to be back in the city since most of us were in rural areas for our rotation.

Within the first week of classes,  though we quickly realized that it wasn’t going to be a cake walk, we were all still optimistic that it wasn’t possible to be worse than the stress and rigor we experience the year before.   As the projects and presentations began adding up in each class, it was soon clear that this semester would be far busier than first year. Instead of spending our Sunday’s frantically studying for the week ahead (or playing catch up from the previous week), we were sifting through Google Docs and Google Slides to figure out which presentation was a priority that day and when we needed to meet up with our group members to rehearse and review.

Now that we’re almost done with the first semester of second year and we’ve had
time to reflect while eating too much food during Thanksgiving break, many of us have
realized that this year has been just as hard as first year,  though in a different kind of way. I don’t go home and have a panic attack about how much studying I have to do or how many tests would be taking that following week.  My stress and anxiety is now from the number of presentations I have to give, despite my fear of public speaking , on top of studying for exams, being a tutor, and working in our service learning clinic every week.

Now, we all look to the third years, who are off on their rotations around the country
and are done with didactics, in envy and hope that one day we’ll make it to where they are. Past the seemingly never-ending sea of tests and projects of PT school.

 


 Looking at the landscape of physical therapy practice management, we see a playing field tipped to benefit the payers and hurt the provider. The relationship between payers and providers is adversarial, but billing networks offer solid strategies that allow providers to get back into–and win–the game.

The “network effect” allows a large number of unique providers to capitalize upon their strength in numbers.  Please help us strengthen that network.

If your friend schedules a demonstration of the system, we’ll send you a $25 Amazon gift card
For each friend that you refer that joins our network, we’ll credit you $50 each month the office is contracted with us through the first year!



Nov 2017 Newsletter: Teaching Documentation in a DPT Program

November, 2017 Newsletter

Teaching Documentation in a DPT Program

by Tiffany Enache, PT, DPT, Assistant Professor and Director of Clinical Education

Documentation is an important part of the daily life of a physical therapist, and APTA presents high standards in their Defensible Documentation resources (1) and also in the Guide to Physical Therapist Practice (2).  These both serve as very useful resources when designing learning experiences related to documentation in a Doctor of Physical Therapy (DPT) curriculum.  There are many challenges in teaching physical therapy documentation in a DPT curriculum, one of which is the variety of templates that exist throughout differing clinical settings, both in written template format and in electronic format.  Students in our DPT program expressed confusion when each faculty member introduced a new documentation template for their specialty setting, and the students similarly struggled to produce high-quality documentation in the clinical setting during their internships.  Our DPT faculty therefore sought to create a template that could be utilized across all physical therapy settings: from outpatient orthopedics to neurologic to pediatric to acute care.  The faculty standardized the way that we teach such aspects as goal writing and narrative assessments, and encouraged our students to be descriptive in the ways that they write about current level of function, motor control, and functional mobility.  With one consistent framework for teaching documentation, our students grew in skills and articulation, and documentation shifted from a curricular weakness to a curricular strength.

The final remaining challenge was to utilize an Electronic Health Record (EHR) system to teach documentation.  Even though our students were demonstrating significant improvements in their documentation skills, the way that we were teaching documentation, as one student stated, “needed updating”.  In the search for an EHR that would meet our needs, there were several features we were looking for: 1) a template that was intuitive enough for both novice learners and faculty; 2) a template that included sufficient breadth to cover all physical therapy settings; 3) a template that encompassed the high standards presented by APTA; 4) an interface that would pass university internet security review; 5) an interface that would be compatible with the academic learning environment; and 6) a company that would be willing to price their product fairly, considering that it would not be used to generate revenue.  

The DPT academic faculty excluded many EHR systems due to price, a common finding being that there was either no price model available for a usage that did not involve billing, or the base price significantly exceeded the budget of the department and would therefore increase the financial burden on the students.  The next triage of exclusion related to the template design.  Now that our students were finally understanding documentation standards, we felt it critical that we not lower our standards in order to embrace the EHR world.  We became increasingly frustrated as we reviewed templates that either lacked high standards, did too much of the work for the student (thereby decreasing their clinical reasoning), or were not usable across different physical therapy settings (many EHRs are built for the outpatient adult orthopedic population).  We struggled to find an EHR company that was willing to customize a template for us, especially considering our financial constraints.

Our solution was bestPT by Billing Dynamix.  From the very first conversation, their sales team was willing to listen to our needs and offered to create a template that met all of our requirements at a fair price.  Even though they had never before offered their EHR for use in the academic setting, they saw the value not only in this collaboration, but also the value in educating future professionals in the field.  We currently use Billing Dynamix for various classroom activities.  For example, students early in the program will enter data into the EHR as their professor conducts a patient examination in front of the class.  This is an excellent introductory learning activity because the instructor can then use the EHR to write up his/her initial evaluation, then spend class time explaining their choice in wording, the location of particular content, and how a narrative assessment, goals, and treatment plan are constructed.  Intermediate and advanced students in the program use the EHR during simulated patient encounters, and are graded on their documentation content and structure.  Future hopes for this EHR include use at the program’s pro bono clinic.  We have been able to construct our EHR templates to give just enough prompting to provide guidance to novice learners, yet not so much prompting such that students would lose the opportunity for development of clinical reasoning and professional language.  

Thank you, Billing Dynamix, for this collaboration.  You are helping to elevate the standards for future DPT professionals!  I look forward to a longstanding relationship with your company.

Tiffany, PT, DPT

(1) http://www.apta.org/Documentation/DefensibleDocumentation/

(2) http://guidetoptpractice.apta.org/

 

 


 
Let’s welcome bestPT Billing’s newest members!
Harry Morgan & Samantha Andrew
 
Mallory Boyd & Stephanie Petrycki
Bit-by-Bit Therapy, Ft Lauderdale, FL
 
Stephanie Grace
 
Amanda Newman
 
Walden Parsons
Integrated Mechanical Care, Sandy Springs, SC
 
Travis Smith
O&W Enterprises,  Stanleytown, VA
Melissa Talley, Roslyn Evans, Carol Howder,
Joanne Principe, & Lisa Ingenito
 

Each new member benefits from and contributes to our network strength.

 


 Looking at the landscape of physical therapy practice management, we see a playing field tipped to benefit the payers and hurt the provider. The relationship between payers and providers is adversarial, but billing networks offer solid strategies that allow providers to get back into–and win–the game.

The “network effect” allows a large number of unique providers to capitalize upon their strength in numbers.  Please help us strengthen that network.

If your friend schedules a demonstration of the system, we’ll send you a $25 Amazon gift card
For each friend that you refer that joins our network, we’ll credit you $50 each month the office is contracted with us through the first year!



physical therapy billing software ICD-10 cartoon

A New Online Learning Tool On How to Reduce ICD-10 Transition Pain for Physical Therapy Practice Owners

ICD-10 GEMs PLUS Solution Is Now Available with bestPT Billing and EHR Software

bestPT Billing and EHR Software helps their clients make a smooth transition to ICD-10. Their 5 part strategy called bestPT GEMs Plus ensures that Physical Therapists make the best ICD-10 code selection. bestPT’s code selection tool remains effective beyond the transition helping practice owners to keep up with continuous changes inflicted by insurance companies. Click here to learn more.

According to Dr. Eldad De-Medonsa, bestPTs’ President and PhD in Artificial Intelligence, the effects of the transition to ICD-10 will remain unknown for some time. “The only thing that is certain about the transition to ICD-10 is that insurance companies leverage its challenges and uncertainties to delay longer and underpay more insurance claims. Because of a huge increase in the number of codes, a simple one-to-one mapping between the old and the new codes does not exist, as demonstrated in the standard GEMs tool. We leverage the cloud, billing experts, and Artificial Intelligence to analyze millions of insurance claims and generate effective transition rules,” says De-Medonsa.

Click here to learn more.

About BestPT and Billing Dynamix, LLC.:
BestPT by Billing Dynamix is a comprehensive cloud-based Physical Therapy Practice Management system that includes intuitive EMR, industry-leading billing, scheduling, and powerful yet simple workflow management. Save documentation time and keep legible and compliant documents. Automate claims and leverage over 2.5 million coding rules spanning 2,500 practice-years of experience. Reduce administrative overhead and foster staff teamwork. bestPT is the ONLY Physical Therapy clinic solution that reduces administrative time by 70% compared to industry averages – GUARANTEED. Complete practice management consulting and a rich array of integrated products and services round out bestPT product and service packages. Register for a private Demo+, and review our industry-leading guarantee.

physical therapy billing cartoon

A New Online Learning Tool On How to Accelerate Physical Therapy Practice Growth Using Checklists

Checklist Technology Is Now Available in bestPT Billing and EHR Software

Practice owners fail to control and scale up patient visit experience when they rely exclusively on their memory and do not measure their practice performance. Without measuring, practice owners do not know that they have a revenue or a patient retention problem. Learn about it here.

According to Jason Barnes, COO for bestPT Billing and EHR Software, the first step in building any repeatable and scalable process is to define process performance and uniformity metrics. “The tasks are grouped together in a category for tracking purposes. The tasks can then be measured using the Task Manager Console across all patients or filtered down to a patient, to measure the success of the process across the practice or with an individual,” says Barnes. “For instance, the patient intake process might have 10 steps. If one of the steps is neglected, the problem would be manifested by the Task Manager Console reading a completion rate of 90%. The tasks can be sorted and the offending task can be rooted out and either changed or have additional staff training to achieve better results.”

Learn about bestPT Billing and EMR Software checklist technology here.

About BestPT and Billing Dynamix, LLC.:
BestPT by Billing Dynamix is a comprehensive cloud-based Physical Therapy Practice Management system that includes intuitive EMR, industry-leading billing, scheduling, and powerful yet simple workflow management. Save documentation time and keep legible and compliant documents. Automate claims and leverage over 2.5 million coding rules spanning 2,500 practice-years of experience. Reduce administrative overhead and foster staff teamwork. bestPT is the ONLY Physical Therapy clinic solution that reduces administrative time by 70% compared to industry averages – GUARANTEED. Complete practice management consulting and a rich array of integrated products and services round out bestPT product and service packages. Register for a private Demo+, and review our industry-leading guarantee.

physical therapy billing cartoon

Physical Therapists Now Use bestPT’s Workflow System to Manage Revenue Cycle and Improve Billing Processes

bestPT adds powerful new reporting features to its revenue cycle workflow control software to help practice owners improve collections and profitability

CLEARWATER, FLORIDA (PRWEB) JUNE 21, 2015

bestPT simplifies revenue cycle management through the use of it’s revolutionary workflow management process. More money to the practice creates financial stability for the owner and the employees and results in a stronger practice that is able to grow and serve more patients. Transparent reporting includes real-time automated alerts to notify process owners and participants about any problems or delays. This system enables practice owners to keep track of their claims, along with all other relevant work, in a single location. bestPT helps practice owners create a systematic revenue cycle management improvement process while providing them complete quality monitoring and control. View our free webinar here to learn more.

See exactly which claims were underpaid or delayed, and what needs to be done to fix that.

According to David Alben, the princial consultant at Genco Healthcare Management, the efficiency of bestPT system is the reason why their reimbursements are paid in full and on time. “Which claims have been paid and which claims haven’t been paid? Who owes you the money? How long have they owed you the money? The whole issue between insurance approved amount and usual and customary charges. All of those things are confusing. Insurance companies have placed barriers to payments because it’s in their interest to do that.”

According to Tom Jorno, PT Excellence Center Director at Billing Dynamix, bestPT’s Revenue Cycle Workflow automates the process of claim submission, follow up, and control. “Claims are automatically created with a preselected fee schedule and scrubbed against millions of rules prior to submission,” says Jorno. “The software allows them to see exactly which claims were underpaid or delayed, and what needs to be done to fix that.”

At the end of the day, bestPT summarizes all of this information into a single metric that can be monitored helping ensure that no claim is left behind and every underpayment or delay has been followed up on. The practice only has to clear one backlog a day with specifically worded instructions to maximize revenue. Any claim not addressed is easily identified by both practice stakeholder and practice success coach to locate the breakdown in process or ownership. Click here to sign up for the free webinar about bestPT’s workflow.

About BestPT and Billing Dynamix, LLC 
BestPT by Billing Dynamix is a comprehensive cloud-based Physical Therapy Practice Management system that includes intuitive EMR, industry-leading billing, scheduling, and powerful yet simple workflow management. Save documentation time and keep legible and compliant documents. Automate claims and leverage over 2.5 million coding rules spanning 2,500 practice-years of experience. Reduce administrative overhead and foster staff teamwork. BestPT is the ONLY Physical Therapy clinic solution that reduces administrative time by 70% compared to industry averages – GUARANTEED. Complete practice management consulting and a rich array of integrated products and services round out bestPT product and service packages. Register for a private Demo+, and review our industry-leading guarantee.

physical therapy billing is painless

What We Say When We Talk to Our Patients About Pain

As physical therapists we know the scenario quite well. The new patient intake forms come across our desk right before an evaluation and the body chart is completely covered in “X” marks indicating areas of pain. There is no clear nerve root pattern, no dermal pattern, no pattern at all – just X’s spanning across the body. Perhaps there was an initial trauma several years prior, though many times the onset is insidious.

Often times the medication list is extensive and includes opiates or narcotics. During the history taking portion of the evaluation the patients often recounts a long tail of failed medical remedies. Perhaps they have seen countless health care professionals of various types in various locations. Perhaps they express disdain that their physician has sent them to you because in the past physical therapy has done nothing for them. And perhaps a little voice inside our head gives a deep sigh and says “oh dear.”

There is growing concern over distribution and overuse of opioids by chronic pain patients. Medical practitioners are under pressure by third party payers and the medical boards to prescribe in a safe and conservative manner, though due to the addictive nature of the opioids and narcotics, when denied continuous access to medications some patients may seek a string of new physicians.1 While there is evidence to suggest that opioids can provide analgesic effects to a chronic pain patient for up to eight weeks, they have not been seen to provide pain relief for the same dose after 2 months. 1

Further conversation with our chronic pain patient may reveal how horrified the patient truly is at how their pain has been managed. We know that most of them are not drug seekers for the sake of drug seeking. Chronic and excruciating pain has lead them to seek whatever may get them through their day and many times the pain medications offer a window of relief.

We as physical therapists are the most equipped health care professionals to treat patients with chronic pain. So why then have we found ourselves beating our heads against our desk when we fail to make them better?

Lorimer Mosely, David Butler, Paul Hodges, and Adriaan Louw suggest that we explain pain to them to get them better. These physical therapists come from various research groups using MRI, Ultrasound imaging, mirrors, and various other techniques to develop a profound understanding of what pain is, how it behaves, and what we can do to treat patients suffering from it.

Books such as Explain Pain by Mosely and Butler (of the Neuro Orthopaedic Institute) use beautiful art and laymen’s terms to explain these concepts to patients and healthcare providers alike.2 Mosely’s book Painful Yarns uses a collection of relatable stories to explain how pain behaves (the Australian term Yarns means stories)3. The gift that Mosely gives to patients and healthcare providers alike is humor. The reader gains a sense of neuroscience through anecdotes and analogies in a empathetic and lighthearted manner.

It is the job of your brain to protect you. This is a process that has been in place since the day you were born to ensure that your needs were met. When your brain perceives a threat to you, it sends a perceivable message of pain.

The importance of this concept is that the ability to correctly and succinctly explain pain to patients is producing results. Anecdotally, it has changed the way I practice. The concept lies in explaining the concept of neuroplasticity, the brain homunculus, and physiological adaptations that take place as a result of the this process. Adriaan Louw of the Spine and Pain Institute explains that the role the sympathetic and parasympathetic nervous system in his series of books Why I Hurt.4 This series of books covers topics including general pain, back surgery, whiplash, as well as pelvic pain.

Louw demonstrates his conversations with patients in several continuing education formats. At the end of the day we as therapists are generally good at reviewing evidence based literature regarding pain, neuroscience, and therapeutic management, though conveying this subject matter to patients with a variety of educational and psychosocial backgrounds can be a challenge. The following dialogue is one that I commonly use during evaluations and treatment sessions with patients. I find that this has enhanced my ability to gain trust and build rapport with chronic pain patients.

I begin by stating that their case is one that I am familiar with. Many patients feel that their symptoms may be baffling since no single health care professional has been able to explain to them why or how their symptoms persist. Often times I hold this conversation during manual therapy when the patient is lying still and is in a relaxed and comfortable position. I assure them that their symptoms are not in their head, though the brain plays an important role in the experience of pain.

I state the following “It is the job of your brain to protect you. This is a process that has been in place since the day you were born to ensure that your needs were met. When your brain perceives a threat to you, it sends a perceivable message of pain. For example, if you fall and sprain your ankle, your brain will tell you that it hurts, so that you will stop walking on it and allow the tendons to rest.

However if you were to step off a curb and sprain your ankle, and a bus was coming at you full speed, your brain would not inform you of pain, but to get out of the way of the bus. It is in this manner that the brain decides what the greatest threat to you is.

If there was an initial injury to the patient that resulted in a chronic pain cycle I would recount the following: Your brain acts like a security system to your body, similar to how a security system would protect a house. If someone threw a brick into the front window of your home and robbed it, you would buy a very loud, noisy security system, and perhaps get a guard dog.

This security system may be so sensitive that it went off when anyone came to the door – not just a criminal. Under a high security threat some alarms go off whenever someone approaches the door. Your brain acts in the same manner to protect your body- it will become weary of normal, non-threatening movements, positions, and activities because it wants to protect you. In this way it can become so sensitive that it does not know the difference between a real threat and a perceived threat. I then explain to the patient that the goal of physical therapy is to address the true mechanical threats and to reteach them safe movements.

This dialogue has opened the doors to communication with my patients. My perception of my practice is that I am earning earlier trust and rapport which merits quicker results with evidence based physical therapy treatment of manual therapy, therapeutic activity, and exercise.

  1. Fields H. The Doctor’s Dilemma. Neuron. 2011 Feb 24; 69(4): 591–594.
  2. Butler D. Mosely L. Explain Pain 2nd Edition. Noigroup Publications; 2013.
  3. Mosely L. Painful Yarns. Dancing Giraffe Press; 2007.
  4. Louw A. Why I Hurt. International Spine and Pain Institute; 1 editiob; 2013.

physical therapy billing and patient scheduling

Physical Therapists Now Use bestPT’s Scheduling Workflow to Manage Patient Relationships

bestPT’s software adds patient appointment quality control to help practice owners improve patient experience

bestPT simplifies scheduling and patient relationship management through the use of it’s revolutionary workflow management process. This system enables practice owners to keep track of their patient visits, along with all other relevant work, in a single location. bestPT helps practice owners create a systematic patient relationship management process while providing them complete quality monitoring and control.

According to Nick Roselli, OTR/L, CHT, owner of NR-OT network of Occupational Therapy practices, the efficiency of bestPT system is the reason why their reimbursements are paid in full and on time. “Do I take this insurance patient and lose money or do I turn them away and risk losing a referral source? That’s everything. You talk about efficiency? That’s efficiency with bestPT.”

According to Tom Jorno, PT Excellence Center Director at Billing Dynamix, bestPT’s Scheduling Workflow automates the process of patient appointment scheduling, follow up, and control. “…it allows the practice owner and their staff to see precisely which patients require attention on any given day. The software allows them to see exactly which patients missed their appointments, which ones don’t have a future appointment scheduled, and what needs to be done to fix that,” says Jorno.

That’s everything. You talk about efficiency? That’s efficiency with bestPT

At the end of the day, bestPT summarizes all of this information into a single metric that can be monitored helping ensure that every missed appointment and every patient without future appointments has been followed up on. Click here to sign up for the free webinar about bestPT’s patient no-show workflow management.

About BestPT and Billing Dynamix, LLC
BestPT by Billing Dynamix is a comprehensive cloud-based Physical Therapy Practice Management system that includes intuitive EMR, industry-leading billing, scheduling, and powerful yet simple workflow management. Save documentation time and keep legible and compliant documents. Automate claims and leverage over 2.5 million coding rules spanning 2,500 practice-years of experience. Reduce administrative overhead and foster staff teamwork. BestPT is the ONLY Physical Therapy clinic solution that reduces administrative time by 70% compared to industry averages – GUARANTEED. Complete practice management consulting and a rich array of integrated products and services round out bestPT product and service packages. Register for a private Demo+, and review our industry-leading guarantee at https://bestptbilling.com/

physical therapy billing reimbursement

Reimbursement in Physical Therapy

On April 16, 2015 Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act is intended to repeal the flawed sustainable growth rate (SGR) formula, and is the final and permanent piece of legislation in a long line of annual temporary adjustments since 2003 that had prevented the SGR from activating a large payment cut for physical therapists and other healthcare professionals. Most importantly, MACRA further extends the Medicare therapy cap exceptions process to December 31, 2017, and includes numerous other provisions that will impact physical therapy. With the passage of this law, Congress has laid the groundwork for significant changes to Medicare reimbursement for physical therapists and other health care professionals1.

Active immediately, physical therapists can expect to see a positive payment update of 0.5% from July of 2015-2019. Physical therapists and other health care professionals who participate in alternative payment models (APM) will receive a 5% bonus annually from 2019-2024, and the fee for service model is retained. In 2026 and beyond, physicians, physical therapists, and other health care professionals in APMs may qualify for a 0.75% annual update. PT’s participating in all other payment plans will receive a 0.25% annual update. Perhaps the most exciting upcoming advancement is the fact that technical support is provided for smaller practices, funded at $20 million per year from 2016 to 2020, to help them participate in APMs or the new fee-for-service incentive program1.

The rumblings surrounding fee for performance reimbursement will be realized in 2019. Specifically, current quality incentive and payment programs such as the Physician Quality Reporting System (PQRS) will be consolidated and streamlined into a program called the Merit-Based Incentive Payment System (MIPS) beginning in 2019. This change will be best undertaken with early implementation and use of electronic medical records to assist in tracking appropriate reporting2. A detailed list of physical therapy outcomes tools and procedures for PQRS reporting can be found at: http://www.apta.org/PQRS/, and http://ptjournal.apta.org/cgi/collection/outcomes_measurement.3

Notably, changes have also been made to the infamous Medicare Cap. MACRA provisions to the Medicare therapy cap include an annual amount of $1,940 for physical therapy and speech language pathology combined in 2015, with a separate $1,940 cap for occupational therapy.  Hospital outpatient claims for therapy services with dates of service through December 31, 2017 will continue to apply to the therapy caps. In the event that further physical therapy is deemed medically necessary, providers may obtain an exception to the therapy cap until December 31, 2017. The manual medical review process at $3,700 has been replaced with a new medical review process that becomes effective 90 days after enactment of the law, which will be right around the corner in mid-July, 2015. This new annual review process applies to exception requests for which a medical review had not been conducted by the July date.1

In the private practice domain, physical therapists can expect to continue to report in the PQRS program in 2015, however changes to to the quality reporting system will take place in 2019. Beginning in 2019, the current quality programs under Medicare part B for physicians (PQRS, Value-Based Modifier, EHR Meaningful Use) will be consolidated and replaced with a new program called the Merit-Based Incentive Payment System (MIPS)1. Performance in MIPS will be based on 4 domains: quality, resource use, meaningful use, and clinical practice improvement activities.  MIPS will implement penalties for low performing clinicians and incentives for high-performing providers and practices. Bonuses and penalties under MIPS begin at 4% in 2019 and increase to 9% in 2022.  Data-reporting under MIPS will be via electronic reporting mechanisms (such as registries). Participation in a qualified clinical data registry would also count as a clinical practice improvement activity1. It is again here where we see the value in early adoption of electronic medical record use.

All of these changes and reform should result in better and more accurate reimbursement according to the American Physical Therapy Association (APTA). “It’s an exciting time, to have this finally happening,” Helene Fearon, PT, FAPTA, said at the conclusion of the June 6, 2015 APTA session titled “Payment for Physical Therapy Care Is Changing.” The session looked at the past, present, and future of efforts to shift payment for physical therapist services under Medicare from a fee-for-service model to what another speaker, APTA Senior Director of Payment and Practice Management Carmen Elliott, called a “value mindset.”4

A look back at the Department of Health and Human Services’ mandate under the Affordable Act to meet the “triple aim” of payment reform “better quality of care, improved public health, and lower cost”and APTA’s development of the Physical Therapy Classification and Payment System (PTCPS). The PTCPS differentiates Current Procedural Terminology (CPT) evaluation codes by level of complexity for the physical therapist (PT), and further differentiates intervention codes by severity of patient condition and intensity of PT services provided. Fearon, considered one of the profession’s preeminent experts on documentation, coding, billing, and payment-related policy issues, provides greater detail on the changes for which APTA has been working, listed in full at www.apta.org/PTCPS/.4

These revisions are intended to change the payment model from isolated visit to episodic, and considers the clinical judgment of the PT, while taking into account the severity of the condition and intensity of PT’s involvement in care. In addition to APTA’s PTCPS page, two additional documents on alternative payment methodology as particularly relevant for PT’s the Medicare Benefit Policy Manual and the ICF (International Classification of Function, Disease, and Health) “beginners guide” Toward a Common Language for Functioning, Disability, and Health.4

  1. Highlights of the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10). American Physical Therapy Association. Available at: http://www.apta.org/Payment/Medicare/. Accessed on June 24, 2015.
  2. Medicare Physician Quaility Reporting System. American Physical Therapy Association. Available at: http://www.apta.org/PQRS/ . Accessed on June 24,2015.
  3. Outocmes Measurement. American Physical Therapy Association. Available at: http://ptjournal.apta.org/cgi/collection/outcomes_measurement. Accessed on June 24, 2015.
  4. Reform Efforts soon will pay off-literally- experts say. American Physical Therapy Association. Available at: http://www.apta.org/NEXT/News/2015/6/6/Reform/. Accessed on June 25th, 2015. -Amanda Olson, DPT
ICD-10 for physical therapists

Are You Ready for ICD-10? We Are!

 What are you doing for ICD-10?

Is your Physical Therapy practice Ready for ICD-10?

Our bestPT software was ready last year and our Team has made further refinements this year, including testing it thoroughly.  We do not expect the October 1, 2015 deadline to be pushed again like it was last year. We have prepared for it by adding over 65,000 codes to our software and when you choose an ICD-9 code, you’ll be able to choose from the corresponding ICD-10 codes.  We even give you the ability to test everything with a test patient account.  Check with your Practice Profitability Coach for more details.  Not our client yet? Then click in the upper right or the bottom left for a demonstration.