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physical therapy billing is painless
Amanda Olson, DPT, PRPC

What We Say When We Talk to Our Patients About Pain

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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 reimbursement
Amanda Olson, DPT, PRPC

Reimbursement in Physical Therapy

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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
physical therapy billing with ICD-10
Amanda Olson, DPT, PRPC

Is Your Practice Ready for ICD-10?

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The notion that change is inevitable is contrived but true. If at any point health care ceases to change, then we should all be worried, because if there is no change, inevitably there is no growth. The other side of this coin is the notion that change itself produces worry and confusion.

The climate of health care in the United States has been forever changed and, come what may, it will not go back to what it was. Almost in tandem we are all preparing for the global health care change from the current International Classification of Diseases (ICD)-9 to the monolithic ICD-10 coding system. There is no need to enter a sympathetic nervous system frenzy as long as you are educated on what to expect and have an electronic medical record system that will support your business and transfer to the ICD-10 system in real time.

If you visit the government site http://www.cms.gov/Medicare/coding/ICD10/index.html, you will be instantly greeted with a ticking countdown to the October 1, 2015 ICD-10 compliance deadline. Those who are paying attention recognize that the initial set date for implementation was October 1, 2013. As if awaiting a rapidly approaching train in a station, we scrambled in attempts to prepare staff, billing systems, patient’s, anyone involved in implementation or reception of health care.

Then we learned that the change would be delayed one year to October 1, 2014. More scrambling ensued. And then in August we were informed that yet again the change would be delayed for one year to October 1, 2015. Hopefully, this time around, the world will be prepared.

ICD-10 coding compliance pertains to any healthcare provider covered by the Health Insurance Portability Accountability Act.1 This of course includes physical therapists, many which are concerned about the cost surrounding updating their technology and training staff. The center for Medicare and Medicaid services (CMS) has created an online module titled The road to 10 available at: http://www.roadto10.org/. Within this site one may find tips for implementation for small practice. A five step plan is provided in effort to guide practitioners to preparation complete with a printable checklist.

The Road to 10 plan includes steps such as “updating your process” which pertains to analyzing company policies and procedures, and analyzing the quality of documentation supplied by staff. The next step is the elephant in the room for most clinics. This involves engaging with partners and vendors and includes recommendations for technology staff.

The CMS recommends ensuring that your electronic medical record vendor has updated their software and is compliant with all codes updated. A key question to ask is whether or not the version of EMR that you are engaging in has 5010 capability. This will indicate whether or not you are able to submit your diagnostic coding to third party payers3. This is also where grumblings from clinicians who have held out with paper charting may be heard echoing through the canyons.

At this point physical therapists have not been mandated to switch to electronic medical records (EMR), however all of our peers have, including family practice doctors, podiatrists, and chiropractors. It is speculated that this may influence referral patterns to physical therapists from referral sources who do not have the capability to send and receive paper charting from those physical therapists who have declined to engage in EMR.

This may create further barriers for these clinicians when the ICD-10 changes come about as training billing and coding staff who operate on a paper based system may take time away from current clinic tasks, and may result in human errors that can be costly. In this regard, EMR can be an enormous asset to small physical therapy practitioners, and the ability to accurately code, and bill electronically can pay for itself quickly due to expedited and improved reimbursement from payers.

With the fear of change one may seek comfort in the fact that Current Procedural Terminology (CPT) codes will not change for the outpatient realm. What we will find when we receive or implement diagnostic coding under the new system is that the terminology is much lengthier and highly specified.

For example, instead of an ICD-9 code of 724.2 Lumbago, under ICD-10 coding the diagnostic term becomes M54.5 Low back pain due to intervertebral disc displacement, or perhaps M54.5 Low back pain due to pregnancy; the diagnostic code involves mechanism of injury and highly specified features of the low back pain (with or without radiculopathy, etcetera).

The American Physical Therapy Association (APTA) has many resources available to practitioners in anticipation of this change as well. Key practice Impacts of the ICD-10 upgrade, Webinars with suggestions for planning ahead, and an upcoming release of clinical examples of phsyical therapy specific coding are all available at: http://www.apta.org/Payment/Coding/ICD10/.4

In the end, the train that is ICD 10 coding is approaching us, and we must board in order to continue practicing physical therapy. Get yourself a map: The road to 10 by the CMS is a good one, and pack your comfortable shoes. In the end we choose our attitude, we can embrace and enjoy this trip with the right amount of preparation and protection from appropriately updated EMR as our insurance. bestPT EMR is ready for ICD 10 and staff is available to guide each individual practice in their implementation of our new coding system.

  1. ICD-10. Centers for Medicare and Medicaid Services. Available at: http://www.cms.gov/Medicare/coding/ICD10/index.html . Accessed on June 3rd 2015.
  2. The road to 10: The small physician practice’s route to ICD 10. Centers for Medicare and Medicaid services. Available at:  http://www.roadto10.org/. Accessed on June 4th 2015.
  3. ICD 10 Fact Sheet: Basics for small and rural practices. Available at: http://www.cms.gov/eHealth/downloads/eHealthU_BasicsSmallRuralPrac.pdf. Accessed on June 4th 2015.
  4. ICD 10. American Physical Therapy Association. Available at: http://www.apta.org/Payment/Coding/ICD10. Accessed on: June 4th 2015.

-Amanda Olson, DPT

PQRS
Amanda Olson, DPT, PRPC

2015 Changes in PQRS Reporting Made Easier with EMR

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Previously we discussed the changes in health care provision regarding the Physician Quality Reporting System (PQRS). In this article I will present more in depth current information regarding the ever changing landscape of medicare reimbursement and how physical therapists fit into the picture. In January of this year, the US department of Health and Human Services (HHS) produced the first set of timelines for a transition away from Medicare reimbursement as we know it. The ball is now rolling to move away from a fee-for-service model in favor of a payment for outcomes paradigm. This new model will create a demand for provider accountability and increased quality in patient care in an outcomes-based reimbursement model.

The major changes in PQRS reporting for 2015 drastic changes in fee schedule payment. Specifically, private practice PTs who did not participate in successful reporting of data on quality measures in the form of PQRS reporting in 2013 will see a 1.5% reduction in their fee schedule payment in the year 2015(1). Those who do not successfully participate this year will be see a 2.0% reduction in their fee schedule which will be fully realized in the year 2017.

Additionally, private practice’s will be included in a Value-Based Modifier (VM) program which is set to begin in 2016. Under this new program, PTs must meet PQRS reporting requirements or be subject to up to a 4.0% reduction in payment in addition to the pre-existing 2.0% reduction for a total of 6.0% reduction in pay which will be realized in the year 2018.

The intention behind all of this change is that health care practitioners, including PTs, will provide higher quality services for Medicare beneficiaries. PQRS reporting began in 2007 and in the year 2011 was re-branded and tuned up through the Affordable Care Act. In 2013 it morphed from an incentive-based program to a penalty based program. There is no going back to where we came from, PQRS is here to stay, and a fixture of outpatient physical therapy practice(2).

Interestingly, the VM program utilizes PQRS data collected from clinicians to determine its penalties. Currently, physicians are experiencing these penalties, though the Center for Medicare Services (CMS) has held off on penalizing allied healthcare professionals in order to give adequate time for us to familiarize ourselves with the reporting system. Next year however, we will be held to the same standards, and in order to continue to draw in revenue as we have in the past, we must be compliant with the reporting format.

The regulations are doable. As PTs we must report at least 9 measures, which includes at least 3 National Quality Strategy (NQS) domains on at least 50% of Medicare Part B fee-for-service patients. A complete list of PQRS registries can be found at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html. Depending on the type of patients your clinic sees, some of the domains may be satisfied rather easily with patient intake forms as these include a complete checked list of medications, a pain assessment prior to initiation of patient treatment, and a functional outcome measure. The first two are easily satisfied with patient intake, and the latter may be performed as part of the evaluation of a new patient, and thus readily satisfy Medicare PQRS requirements.

 

There are notable changes in the 2015 reporting, including which cases are eligible for reporting. These changes include elimination of the Back Pain measures group, as well as the Wet to Dry Dressing In Patients with Chronic Skin Ulcers. G code G8406 Diabetic Neurologic Evaluation was removed as well, while G codes G8980, G8983, G8986, G8989 and G8992 were added for FOTO outcomes measures #217-2231.

Medicare PQRS physical therapy

Use of Code #245 is still acceptable in PQRS reporting.

To check your status as a provider, and your clinic’s success in PQRS reporting, the CMS provides claims-based participants with feedback reports through Quality Net, the contracted service provider for Medicare. Visit qnetsupport@sdps.org or call 866-288-8912 to verify that you are on track for a successful reporting year. You may also receive feedback in the way of an Individuals Authorized Access to CMS Computer Services (IACS) account from Quality Net. You can set up an account at www.qualitynet.org/portal/server.pt/community/pqri_home/212#.

Of the two methods of reporting PQRS, the registry reporting method is quickly gaining traction. This may be due to increases in claims based requirements. Thankfully, the American Physical Therapy Association (APTA) has several resources available to ensure successful reporting. A comparison of the registry based reporting versus claims based reporting may be found at the APTA website: http://www.apta.org/PQRS/(3).

Additionally, the Physical Therapy Outcomes Registry is reaching finalization and will provide outpatient PTs with an organized system for collecting data to evaluate patient’s function, in addition to other relevant measures1. This collective data will demonstrate the value of physical therapy in the betterment of our patients. Furthermore, this data may be a highly beneficial tool in our continued advocacy for lightened Medicare Caps, better reimbursement, and improved professional image. More information on this registry may be found at: www.PTOutcomes.com.

All things considered, the essence of all of these changes is to provide the highest quality care for our patients. By demonstrating progress in our patients through functional outcomes measures, we are able to show the value that physical therapy holds in the lives of our patients. What we have intrinsically known for decades, we will now be able to show to Medicare, to our patients, and referral sources.

  1. Smith, H. Compliance Matters. PT in Motion. (8-12) April 2015.
  2. Registry Reporting . Center for Medicare Services. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html. Accessed on April 20, 2015.
  3. Medicare Physician Quality Reporting System. American Physical Therapy Association. Available at: http://www.apta.org/PQRS/. Accessed on April 20, 2015.

-Amanda Olson, DPT

Dr. Amy Vant, DPT

Falls, Exercise and Evidence in Physical Therapy

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Does exercise really help reduce falls? As physical therapists, we educate our clients in the importance of exercise daily.  Of course, we know that exercise truly does reduce fall risk.  Some clients are eager to exercise, experiencing an increase in energy and improved confidence with their mobility and walking. However, others need some convincing to jump on the exercise bandwagon.  As a physical therapist, I love to educate my clients in strategies to keep them as independent and active as possible.  Utilizing medical research studies provides great evidence to support exercise for independence.  Here we will review the correlation between older adults, falls, healthcare and exercise.

According to the Centers for Disease Control and Prevention (CDC), 1 in 3 adults over age 65 years falls each year, in the United States.  Almost half of individuals over age 80 fall each year.  Falls are the leading cause of injury-related death in this age group.  Falls not only impact the independence and quality of life of individuals as they age, but they also are very costly to the healthcare system.  According to the CDC, the direct medical costs of falls among older adults in 2013, was $34 billion.  Because of an aging population, this figure is likely to continue increasing.  The direct costs are calculated by insurance reimbursements for treating fall-related injuries.  This does not include the long term costs for future disability, dependence on others, lost work time and lower quality of life.  It is estimated that the average hospitalization cost for a fall injury is over $35,000.  As therapists, we know that conservative treatment through physical therapy can reduce healthcare costs drastically.  It is much less expensive for insurance companies to pay for 12 visits of physical therapy, than to pay for a hip replacement and all the aftercare necessary.

physical therapy for falls

Those staggering statistics can be a bit discouraging for older adults.  By educating clients in the modifiable risk factors, they can take an active role in reducing their own fall risk.  Research shows that risk factors highly associated with fall risk include: history of falls, balance problems, leg muscle weakness, vision problems, taking more than 4 medications, and difficulty walking.  Many of these factors can be significantly reduced through exercise.  Exercises should focus on leg strengthening, balance training and flexibility.  There are many published medical research studies to support this claim.

In a study systematic review of literature performed by Gillespie et al.(1), 111 clinical trials were reviewed to analyze the efficacy of exercise in reducing fall risk.  The authors concluded that exercise interventions reduce both the risk and rate of falling in older adults.  In another review of literature, Powers et al.(2) examined what type of exercise has the greatest impact on reducing falls.  They found that a program of muscle strengthening and balance training that was individualized to a person’s need (one prescribed by a trained health professional, such as a physical therapist) was highly beneficial.  In addition, they found that Tai Chi group exercise was shown to reduce risk of falls, as was participation in a home hazard assessment and modification session.  Group exercise classes were beneficial, but not as beneficial as individualized exercise programs.  As therapists, we should consider incorporating Tai Chi as part of home exercise programs.  Also, we should educate our patients in home safety strategies to reduce environmental hazards.

In another systematic review of the published literature, 54 trials were analyzed by Sherrington et al.(3), and found that exercise was the single best intervention to prevent falls.  This study noted that the exercise program must challenge the balance and improve muscle strength through resistance training.  The exercise program should be progressive and individualized to the client’s needs and limitations.

The main learning points of these research reviews are that the exercise programs must be tailored to individual limitations.  If the client has limited strength in their hip flexors and trunk, then they will not be able to properly elicit a hip strategy to maintain balance.  Therefore, the exercise program should focus on strengthening those areas of weakness.  In addition, the client’s balance improves, you will need to progress the difficulty of the exercise for continued improvement.  These strategies all seem like common sense to an experienced clinician.  However, sometimes patient’s need to see the proof that therapy can improve their safety and independence as they age.

As therapists, we must be our own advocates.  The physical therapist is a vital component of the healthcare team.  We are the most capable healthcare experts to reduce the risk of falls in aging adults, through a thorough evaluation and treatment plan.  We should empower our clients with a comprehensive and easy to follow home exercise program, in order to further improve their confidence and independence after completion of physical therapy.  So, next time you have a client that is not a believer, show him the evidence that exercise truly does reduce fall risk.

Utilization of outcome measurement tools, functional mobility tasks and simple examination components such as single leg balance, and tandem stance are excellent means of demonstrating improvement in physical performance and reduced fall risk.  Through utilization of bestPT software, we can easily document objective measures and compare pre and post intervention outcomes.  These improvements can be easily faxed, printed and shared with our clients and their other healthcare providers.  You will be able to turn skeptics into therapy believers.

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.

  1. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009 Apr 15;(2): CD007146.
  2. Powers C, Farrokhi S, Moreno J. Can exercise reduce the incidence of falls in the elderly, and, if so, what form of exercise is most effective? Physical Therapy. 2002 Nov vol 82; no 11; 1124-1130.
  3. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull. 2011 Jun;22(3-4): 78-83.

PQRS
Amanda Olson, DPT, PRPC

Meaningful Use and PQRS

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In 2012 the United States Department of Health and Human Services released final rules related to Electronic Health Records (EHR) and Health Information Technology (HIT). The rules require health care practitioners falling under the title of a physician to comply with federal laws, under the title Health Information Technology Act from Congress. The act made it so that pretty much all health care providers except PTs will have to upgrade EHRs to remain compliant through what is termed “Meaningful Use.”1 This list includes medical doctors, osteopathic doctors, podiatrists, optometrists, oral surgeons, dentists, and chiropractors.

The act also specifies payment adjustments for entities and providers that do not meet meaningful use requirements and other program requirements. Physical therapists are not yet defined as eligible professionals for demonstrating meaningful use and, therefore, are not subject to these payment adjustments for failing to demonstrate meaningful use. The American Physical Therapy Association reports that once a while at this time physical therapists are not directly affected by the rules related to meaningful use under Medicare and Medicaid, they should remain aware of issues relating to HIT technology, particularly in this dynamic health care delivery environment.

Thus, outrageously this new act allots credit to these aforementioned eligible health care providers to receive incentive payments (financial reimbursement) for achieving Stage 2 meaningful use requirements of the act with their certified EHR systems. Physical Therapists were not included, yet Chiropractors were. This is interesting, considering that physical therapists coordinate care and provide services by way of direct referral from hospitalists, specialists, and family care physicians at a much more frequent rate than chiropractors do.

As a pelvic practitioner, I exchange images, documents, and prescriptions on a daily basis with primary care physicians, oncologists, gynecologists, obstetricians, general surgeons, gastroenterologists, nurse practitioners, physician assistants, osteopaths, midwives, orthopedists, and naturopath physicians. I am not unique, all outpatient PTs see patients from a wide variety of practices, and all of these folks have been mandated to comply with the Health Information Technology Act. In a few years it is speculated that the various electronic health record systems will communicate with each other, thus physicians from various hospital and clinical settings will be able to access charts and images for any given patient. There are Electronic Health Records that are certified through the Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program. This program helps to ensure that health IT conforms to the standards and certification criteria adopted by the Secretary of Health and Human Services.

We as PTs are faced with an interesting financial paradigm. We are not mandated to participate in the use of Electronic Health Records, nor do we receive financial reimbursement for its use. Yet, all of our colleagues and referral sources will be participating in this program and accessing patient information seemingly seamlessly, without faxing a pile of documents back and forth with each other.

The question becomes, how do we as PTs respond? The PTs who do switch over to an approved electronic health record system may face the realization that referring physicians do not want to fax piles of documents back and forth with non-participating PTs when they can easily and seamlessly communicate information and prescriptive paperwork with PTs who do have and ONC approved EHR system. Hospital based PT systems are by and large participating and compliant in electronic health records and PQRS reporting and may benefit from increasing referrals by other participating practitioners.

On a professional level, the PQRS reporting by PTs demonstrates our value to our patients, third party reimbursement, and referring physicians. Because the reported values are based on functional outcomes measures we are able to objectively quantify the good that we do for our patients. It is a given that for certain oncological, cardiopulmonary, and geriatric diagnosis the goal may be to preserve current function instead of to progress, we may look to patient quality of life (QOL) outcomes measures as well to demonstrate that we have effectively done our job.

BestPT_Medicare_G-codes_functional_outcome

Functional Outcome Reporting

The pain points of all of this are that PTs in the private practice sector may face decreased referrals from physicians for choosing not to participate in EHR and PQRS reporting. Meanwhile, at this time we do not receive medicare credit or immediate financial repercussion from ONC approved use of EHR from our compliance with this act either. The APTA spells it out for us: once in a while physicians and hospitals are the beneficiaries of many of the federal government’s initial efforts to encourage EHR system adoption, they will expect the other providers they work with, including physical therapists, to implement it as well. Patients also may begin to expect their providers to use EHRs to manage their care. It appears that the writing is on the wall, and that it would benefit outpatient physical therapists greatly to comply, lest we be swept out to sea without the support of our referral sources.

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BestPT is an ONC certified Electronic Health Record software and a sustainable solution to this paradigm. Visit APTA’s HIT webpage for resources and updates on HIT program development and legislation, as well as APTA’s related advocacy efforts.

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Medicare Compliant Reporting

 

References:

1. Final Rules on EHR Meaningful Use Incentive Program and HIT Standards Released. PT in Motion News. Available at: http://www.apta.org/PTinMotion/NewsNow/2012/8/24/EHRHITRUles/ Accessed on April 1, 2015.

2. Physician Quality Reporting System List of Eligible Professionals (PQRS). Center for Medicare and Medicaid Services. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf. Accessed on April 1, 2015.

3. Health Information Technology. APTA. Available at: http://www.apta.org/FederalIssues/HIT/. Accessed on April 1, 2015.
About the ONC Health IT Certification Program. ONC Health Certifcation Program. Available at: http://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program. Accessed on April 1, 2015.

4. About the ONC Health IT Certification Program. ONC Health Certification Program. Available at: http://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program

 

-Amanda Olson, DPT

Amanda Olson, DPT, PRPC

Caring for the Complex Pelvic Patient Part III: Outcome and Reflection

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In the third and final installment of this three part series: Caring for the complex patient, we will review the patient’s presentation and discuss the outcomes following treatment and how documentation using bestPT supported the treatment.

The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse (POP). The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.

The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lived at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds. She is an avid runner and aerobics instructor. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.

Physical therapy examination revealed abdominal strength to be 3+/5 on the Kendall scale. The Pelvic Floor Impact Questionaire (PFIQ-7) was utilized as standardized outcome tool. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale. Internal examination and musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.

Treatment technique can be reviewed in the previous post, Caring for the Complex Patient Part II: Treatment Techniques. The patient received manual therapy to the pfannensteil incision including scar mobilization, myofascial release to the abdominal muscles, psoas, hip girdle, and pelvic musculature. She received a progressive pelvic floor muscle and abdominal strengthening program for in clinic and at home. She was progressed from supine position to finally a dynamic co-ordinated exercise program to prepare her for more strenuous activities of daily living and running. Additionally, she received a post-partum educational packet from the APTA and she was educated in safe lifting mechanics for the back and pelvis, as well as self scar tissue management.

The patient attended six physical therapy visits. According to the American Physical Therapy Associations’s “Guide to Physical Therapy”, a clinician can expect a treatment duration of anywhere from 6-36 visits. Her initial sensation of falling out in the pelvic floor subsided significantly. She was able to conduct household activities, lift her toddler or infant with minimal symptoms, and gradually returned to running after approximately two and a half months of physical therapy (approximately three and half months post-partum). She was independent in her home exercises and felt prepared to manage her symptoms independently at the end of the sixth visit. Her goals had been met, and she appeared to understand the importance of maintaining her home exercise program.

The Pfannenstiel incision improved in mobility, and scored a 7/10 on the Vancouver Scar Scale, which was down from her initial score of 10/13. Her final PFIQ score was 5, down from 19. Upon discharge, the prolapse was graded as follows: in supine hooklying Grade I anterior wall, Grade II posterior wall, with bearing down Grade II anterior wall, Grade III posterior wall. In standing the anterior wall was graded I and posterior wall II, and with bearing down the anterior wall was graded II, and posterior wall a grade III.

Upon reflection, this patient had great outcomes which can be attributed to the patient’s motivation and overall adherence to her program. All things considered she may have benefited from the use of Electromyograph (EMG) biofeedback for enhanced learning of pelvic floor muscle isolation. While currently no literature demonstrates benefits of biofeedback specifically for pelvic organ prolapse, there is evidence in support use of biofeedback training for under active pelvic floor muscles associated with urinary incontinence. One may extrapolate that biofeedback may be beneficial in the provision of visual and proprioceptive feedback to enhance pelvic floor muscle strengthening. The patient presented with very good control of the pelvic floor muscles to begin with, thus biofeeedback was not deemed emergent.

Furthernmore, the Pelvic Organ Prolapse/ Urinary Incontinence Sexual Function Questionnaire (PSIQ-12), or the Pelvic Organ Prolapse symptom scale (POP-SS) may have been utilized as an outcome measure, though due to her post-natal status it seemed more pressing to determine the nature of disability across all pelvic floor conditions in relation to her activities of daily living.

Vaginal birth after cesarean is a growing trend, though is still quite rare in some regions of the United States. Understanding the complex nature of the interactions between the impaired pelvic floor following vaginal birth coupled with pre-existing scarring and soft tissue adhesions from prior abdominal or gynecological surgery is necessary in order to address a Pelvic Organ Prolapse. In the event that the patient did not progress with reduction of prolapse symptoms, she would have then been referred to a gynecologist for fitting of a pessary. In this case this was not necessary.

Documentation supported the treatment of this patient throughout. Thankfully, bestPT allows for input of unique characteristics of the patient, and documentation for each treatment session was efficient.

-Amanda Olson, DPT

Amanda Olson, DPT, PRPC

Caring for the Complex Pelvic Patient Part II: Treatment techniques

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In the second installment of this three part series: Caring for the complex patient, we will review the patient’s presentation and discuss the treatment techniques employed and how documentation using bestPT supported the treatment.

The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse (POP). The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.

The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lived at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds. She is an avid runner and aerobics instructor. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.

Physical therapy examination revealed abdominal strength to be 3+/5 on the Kendall scale. The Pelvic Floor Impact Questionaire (PFIQ-7) was utilized as standardized outcome tool. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale. Internal examination and musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.

The first priority of intervention was patient education to avoid bearing down and valsalva maneuvers. Discussion on the day of evaluation included contracting the pelvic floor prior to lifting her toddler or infant, safe lifting spinal mechanics, and breathing technique to avoid abdominal bulging or bearing down. Avoidance of constipation was discussed, though this was not an issue for this patient, nor was weight management. The patient was issued a copy of the American Physical Therapy Association’s postpartum health awareness information brochure to provide further education regarding postpartum back and pelvic pain, pelvic floor muscle care, post partum fatigue, posture, and cesarean scar management.

Following the internal pelvic exam, the patient was given a pelvic floor strengthening program. Given that the role of connective tissue in providing support to the pelvic floor has gained significant emphasis in the literature, it is understood that if the patient does not benefit from a pelvic floor strengthening program than other means of intervention may be warranted. The rationale for intensive strengthening of the pelvic floor muscle to treat POP is that strength training will build up the structural support of the pelvis by elevating the levator plate to a higher resting point, and maintain this position through hypertrophy and improved stiffness of the pelvic floor muscles.

As no single or absolute protocol has been reported to be the absolute gold standard in the literature, pelvic floor muscle (PFM) training was dosed based upon compilation of evidence in the literature, and patient response. Initially the patient was given a program of 80-100 kegels per day, with 4 sets of 10 being 5 second hold, and 4 sets of 10 being 15 second hold to address speed and endurance of the muscles. These numbers were calculated based upon her muscle test scoring durng initial evaluation. Due to her busy schedule and PFM strength of 4/5, she was advised that these could be performed in various positions, including supine hooklying, sitting, and standing. She was educated to gently draw in the abdominals during PFM contraction as transverse abdominis co-contraction has been demonstrated to enhance activation of the pelvic floor.

Progression of PFM exercise and lumbo-pelvic stability exercises were increased each visit as the patient became stronger. Progressions included diaphragmic breathing pattern with pelvic floor muscle contractions, sidelying clams while performing a PFM and transverse abdominis contraction, and quadruped PFM with transverse abdominis contraction. This exercise was progressed by adding an opposite upper and lower extremity lift (commonly referred to by physical therapists as a bird dog). Pelvic brace with cough was added to address co-ordination and timing of PFM contraction prior to increased intra-abdominal force.

Planks in the forward and side position were introduced at the fourth visit with instructions to contract the pelvic floor muscles and transverse abdominis. At this point, the patient was able to sustain this contraction and sense lift of the pelvic floor for approximately 20 seconds. Sit to stand with kegel and small range squats were added as well. At this point in treatment the patient reported that she was already feeling much better, noting a 50% improvement in overall symptoms during activities of daily living.

Manual therapy consisted of myofascial release (MFR) and scar mobilization, and was performed on the first several appointments to address restriction and adhesion from her cesarean scar. The scar was mobilized in all planes by applying gentle pressure to the scar itself and moving it in the caudal-cephalad, medial-lateral, and rotational planes. Myofascial release of the surrounding tissue was performed similarly. Tissue restriction was assessed to be restricted in all planes both above and below the scar.

Treatment consisted of applying gentle pressure downward with the patient positioned comfortably in supine-hooklying with a bolster under the knees. The theory behind MFR is that the pressure will stimulate increased blood flow and subsequent heat production, enhance lymphatic draining, and provide proprioceptive input into the tissue addressed. Treatment technique of this nature can be direct, wherein the tissue is mobilized in the direction of restriction, or indirect wherein the tissue is mobilized away from the direction of restriction, similar to sliding a stuck dresser drawer backwards in attempts to gain a smooth slide outwards.

Both direct and indirect techniques were utilized on this patient due to the fact that she tolerated both quite well. Once pressure was established and direction of restriction determined, which was both superior and inferior to the Pfannenstiel’s incision, and on the left of the incision, gentle pressure was held until a giving way sensation was felt. The patient was educated in self scar massage technique and advised to perform daily. Additionally, strain-counter-strain (SCS) technique was utilized to release tight and shortened iliopsoas muscles bilaterally.

Muscle energy technique (MET) was utilized in order to re-establish symmetry to the sacroiliac joints of the pelvis. The pubic shotgun technique was utilized prior to torsion MET to draw the left anterior innominate posteriorly and thus level with the right. The patient responded extremely well to treatment. The final installation of this three part series will discuss her outcomes and provide insight to other possible treatment techniques for this patient population.

-Amanda Olson, DPT

Amanda Olson, DPT, PRPC

Caring for the complex pelvic patient with Physical Therapy

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Physical therapists specializing in pelvic health are confronted with a myriad of pelvic floor diagnoses and impairments which may result in pelvic organ prolapse (POP). Pelvic floor weakness secondary to muscle fiber damage or connective tissue abnormality may account for this phenomenon. Extenuating circumstances, such as a vaginal birth after cesarean section (VBAC), add further dimension to the patient’s presentation clinically. A 2014 study suggests that 65% of women experience successful VBAC deliveries, and there seems to be a growing trend of women requesting them.

I recently had the privilege to treat such a woman in the clinic. The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse. The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. This three part series will analyze how documentation supported the evaluation, treatment, and outcomes of the patient.

At the time of initial evaluation her physician had not assigned a grade to her pelvic floor prolapse. Furthermore, the patient had not been evaluated for prolapse during cough; bear down, or in standing position, per patient report. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.

The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lives at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds.

She is an avid runner and aerobics instructor. She reports that there is good stress in her life with the birth of her second child. She was concerned that she would be unable to safely lift her toddler, run, or teach classes in her current state. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.

Physical Therapy Electronic Documentation

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Past medical history is easily entered and accessible in the electronic chart.

There is burgeoning evidence to support physical therapy intervention for pelvic organ prolapse. A Cochrane Database System Review analyzed three randomized control trials (RCT’s) and found that pelvic floor muscle training may result in prevention of symptom worsening, and better self-reported patient outcomes. Furthermore, there is Level I evidence via 3-D ultrasonography that supervised pelvic floor training can increase PFM volume, close the levator hiatus, shorten muscle length, and elevate the resting position of the bladder and rectum in patients with POP. The researchers noted improvement in muscle thickness in both stage I POP and in symptomatic women with stage II or greater as determined by the Pelvic Organ Prolapse Quantification Scale (POP-Q).

As a measure of functional outcome, the patient was asked to complete the Pelvic Floor Impact Questionnaire-short form 7 (PFIQ-7). This outcome measure is a patient report of impact of symptoms of bladder, bowel, and prolapse impairments, and allows the therapist to gauge the level of impact and frustration that the patient experiences due to their symptoms so that treatment may be tailored to fit their individual needs. The PFIQ-7 was found in long form to be valid and reliable for women with disorders of pelvic floor including urinary and fecal incontinence, as well as pelvic organ prolapse. It is internally consistent (0.96-0.97), and reproducible (0.77-0.92), and the prolapse section was found to be significantly correlated with the stage of prolapse of the individual. The short form is faster for the patient to complete, and was found to maintain excellent correlation with the long form (r=0.95 to 0.96), with test-retest reliability P<.001). The outcome may be analyzed in subsets for bladder, bowel, and pelvic symptoms, respectively. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale.

Musculoskeletal screening included assessment of posture in standing and sitting as this can be beneficial as an assessment of structural alignment according to the American Physical Therapy Association’s Guide to Clinical Practice 2nd Edition. The patient demonstrated mild forward head, mild anterior shoulder positioning with mildly increased thoracic kyphosis and lumbar lordosis. Pelvic symmetry was assessed by palpating the bony landmarks of the anterior superior iliac spine (ASIS) bilaterally, and the pelvis was mildly anterior rotated on the left. This pelvic position was verified in the supine position to account for possible interaction of limb length discrepancy. Limb length was measured and found to be insignificant with the right lower extremity measuring 1 millimeter longer than the right. Abdominal strength was graded 3+/5 as she was able to lower her legs no greater than a 60 degree angle while maintaining posterior pelvic tilt, according to Kendall’s muscle testing scheme.

PT examination sought to determine the nature of the heaviness in the pelvis through observation and palpation of the pelvic floor in supine hook lying position. This is done in order to assess the response of the pelvic floor and determine which walls of the pelvic floor appear to be affected.
Musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.

Physical Therapy Electronic records

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Documentation to demonstrate verbal and written consent for external and internal pelvic floor examination are pertinent.

bestPT is able to create unique objective components to demonstrate that consent has been verified. Furthermore it is possible to scan in and attach release forms that have been signed by the patient.

In the next installment, we will discuss treatment techniques in this unique women’s health sub-population.

-Amanda Olson, DPT

Dr. Amy Vant, DPT

Outcome Measurement Tools As Evidence

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Outcome Measurement Tools as Evidence

In a day of medicine in which physical therapists feel stressed by increasing demands for specified insurance guidelines, codes, and outcome measures, it serves a therapist well to have a great understanding of various outcome measurement tools.  Standardized outcome measurement tools are vital to a therapist’s ability to establish baseline performance and track change over time.  In addition, good outcome measurement tools have high inter-tester reliability, making them easily replicated by another therapist.  This means that if I do an evaluation and my colleague were to perform the reassessment, my scoring methods will remain in line with each other.

The beauty of outcome measurement tools is that they provide evidence as to what improvements my patient makes as a result of therapy.  If any of my claims go to review or I need to submit an appeal for denied coverage, using proper outcome measurement tools gives I justification for services.  Nowadays it seems like insurance representatives scour medical documents, looking for any reason they can to deny payment.  As a therapist, my job is to fill my documentation with reasons that they must pay.  They key to this evidence lies in choosing an appropriate outcome measurement tool for my patient.

Physical Therapy Outcome Measurement Tools

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Figure 1. Data “persists” from document-to-document and within one document. This means you can view Prior or Current Levels or Goals from any of the relevant sections

First, I determine what my primary patient population will be.  There are functional outcome measurements that are specific to predicting fall risk or rating extent of disabilities.  These types of outcome measurements are ideal for the therapist working with the geriatric population in various settings.  There are many outcome measurements tools that test specific body parts, such as functional use of an arm or a leg.  In addition, there are many pediatric specific outcome measurement tools.  Because of high interest in research, more and more outcome measurement tools are being created each year, by highly motivated and dedicated clinicians.  I find the type of outcome measurement tool I are seeking and then I become well acquainted with it.

Outcome measurement tools should not take long to administer and should be easily recreated and repeated.  If I am learning how to administer a new tool, I try practicing with an experienced clinician.  I have the clinician present as a patient might and administer the testing items.  After I perform a test a few times, I will likely master it.

Outlined are several common and highly reliable outcome measurement tools based on topic:

Geriatrics: Tinetti Outcome Measurement Tool, BERG Balance Scale, BESTest, Functional Independence Measure (FIM)

Pediatrics: Alberta Infant Motor Scale, Batelle Developmental Inventory, Peabody Developmental Motor Scale, Pediatric Evaluation of Disability Inventory

Upper Extremity: Disability of Arm and Shoulder and Hand (DASH), Penn Shoulder Score, Shoulder Pain and Disability Index (SPADI)

Lower Extremity: Lower Extremity Functional Scale (LEFS), Get Up and Go, Six Minute Walk Test, Lysholm Score

Functional Mobility: Timed Up and Go (TUG), Six Minute Walk Test, Get Up and Go

Physical Therapy Outcome Measurement Tools

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Figure 2. Only relevant fields appear for selected functions. No unnecessary fields get in the way.

The beauty of outcome measurement tools is that they are standardized and tested in the literature.  Once I become familiar with some of the most common outcome measurement tools used in therapy, I can more readily understand current evidence and quickly understand the functional status of my patients.  When documenting within the bestPT software, I can easily utilize outcome measurement tools.  I simply select the outcome measurement tool I would like to input in my evaluation or reassessment note.  You can easily compare my patient’s evaluation score with their (hopefully improved) score at discharge.  This evidence of improvement serves to satisfy me as a therapist, the patient, and the insurance payers.

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.