Let's Help Each Other

Physical therapy is changing rapidly. As a PT with more than thirty years of experience, the changes observed in the last ten years triple those of the first twenty years. The pace of change is not slowing down. The Medigraph Blog will serve as a forum that will enable us to exchange ideas and assist each other. This blog will be used to share billing, documentation, and any other ideas to improve any aspects of our profession. If we share what we have learned, we can develop a resource that enables our collective understanding to advance our careers.

As profit margins grow smaller and expenses grow larger, we need to assist each other to survive and prosper. If we share our experiences we can help each other to grow professionally, administratively, and financially. Our professional lives, our livelihood, and our personal lives are intertwined. Our resources individually are limited. Together we can accomplish more than we can individually. Let's help each other


Tom Kane, PT
MediGraph Software

Documenting Functional Limitations to Avoid RACs
5/3/2011 1:35:00 PM

In 2011, Medicare will change its focus from auditing inpatient facilities to out patient providers.  Remember, RACs (Random Audit Contractors) only get paid if they obtain a refund for services that you have rendered.  RACs sift through your data to find triggers that propmt a review.  These audit triggers  include:

  1. Un-timed codes
  2. The 8 minute rule.
  3. One on one CPT codes.
  4. The 15 minute CPT codes definitions as the basis of patient encounters.
  5. Time in-time out documentation.
  6. Physician certification of the plan of care and the 90 day physician re-certification.
  7. Kx modifier use.
  8. Demonstrating that skilled therapy was required.
  9. Supervision of PTAs. 
  10. Writing a progress note every tenth visit, or, 30 days (whichever occurs first).  
  11. Not using the SOAP note format.

The above list is not new information to most MediGraph subscribers that read our blog.  However, the above list does not desribe the retrospective data mining by a RAC trigger that provokes a RAC audit.   The documentation trigger associated with a RAC complex review is the need to prove that intervention was medically necessary.   A question to consider is, "How did you come to the decision that treatment was necessary?"   Many therapists falsely assume that point 8 from the above list (Demonstrating the need for skilled care) satisfies the medically necessary requirement for providing care.  Unfortunately, demonstrating that skilled care was clinically indicated does not automatically prove that care was medically necessary according to Medicare.  Confused?  Read on.

Imagine a patient, Mr. Jones,  presented with complaints of pain in his left knee.  Examination reveals limited range of motion in the knee and strength testing reveals decreased strength when compared to the unaffected knee.   Further evaluation reveals that a contributing  cause of Mr. Jones'''''''' condition is  limited distal movement of the patella.  You appropriately suggest joint mobilization to restore patellar glide, increase ROM, and reduce pain.   To restore strength th-ex is also suggested, and more prepatory modalaties are suggested as well (US, Estim, etc.).   As sound as these clinical  decision may be,  they do not satisfy the requirement to demonstrate that intervention was medically necessary. 

 To establish that intervention was necessary we must demonstrate that Mr. Jones'' functional ability has been compromised by his impairments.  For example, if  Mr. Jones impairments do not reduce function (ambulate independently, ambulate stairs,  rise from a seated position) it will be a problem justifying the need for care (even though clinically, we all know that he needs treatment).    To provide the intervention the patient obviously needs, and satisfy the bureaucrats and RAC auditors, we must employ objective evidence based  functional assessments that have been pre-established in the literature that confirm a functional deficit.  In Mr. Jones'' case, we may want to employ the Six Minute Walk test, the Timed Up and Go, Tinetti, or any of the 14 gait and balance tests in MediGraph to demonstrate a functional deficit.  These measures wcan also be used to measure and establish progress. 

Though this approach may seem unnecessary to the purist among us, I assure that unless we recognize the documentation requirements that are employed by CMS and RACs are one of the wedges they employ to reduce our fees we will learn the hard way that clinical competence is not enough to operate a successful facility.  By employing MediGraph to satisfy the standards being demanded by Medicare and other private insurers, you can provide the level of care your patients deserve while beating the paper pushers at their own game.

Be well,
Tom Kane, PT
MediGraph Software