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

Regards,

Tom Kane, PT
MediGraph Software

Defining "Medically Necessary' for Physical Therapy
11/30/2011 9:53:00 PM

Defining “Medically Necessary” for Physical Therapy

 We at MediGraph are in a unique position.  As Physical therapy software providers, we are presented with ongoing opportunities to interact with our subscribers and receive feedback when updating our program.  However, another area of important feedback comes from potential subscribers.  We often receive calls from therapists that are looking for documentation software because of a bad experience with a RAC audit.  These therapists experience the hard way what we at MediGraph have been addressing for years; objective standards are required to satisfy the ‘medically necessary’ component of intervention.  It does not matter if your treatment was appropriate.  It does not matter if your skills enabled the patient to overcome a physical impairment.  It does not matter if you increased the patient’s functional ability.  What matters is your ability to prove that what you provide is ‘medically necessary’. 

 As previously stated for our subscribers, RAC audits resemble IRS audits.  Both of these government sponsored hunting expeditions are poorly defined.  When the unstated goal is recapturing revenue, vagueness helps the RAC auditor to establish cause for obtaining a refund of your fees, just as the ambiguity found in the thousands of pages of the IRS code helps the IRS agent to extract their pound of flesh.   

 While there is case law to establish that physical therapists’ judgments are based on their ability to evaluate the patient’s condition (not based on the referring physician), this degree of autonomy does not satisfy the medically necessary standard for CMS or for RACS.  In a recent APTA podcast, the Stanford University Center for Health Policy: Model contractual language for medical necessity was mentioned as the model for determining what is medically necessary.   Five pillars were mentioned as the basis for satisfying the necessity standard: authority, purpose, scope, evidence, and value.  While these five pillars should be the components of sound clinical decisions, it is the last two categories, evidence and value, that the RAC auditors utilize to define medically necessary and are the two areas that require the most attention.

 Evidence that intervention was necessary is easily established, yet the most susceptible area where PTs fall short in their documentation to RACs.   Value, as stated in the Stanford model, is defined as the likelihood of the intervention to “Improve function, minimize loss of function, or decrease risk of injury and disease.”  Evidence and value are easily measured.  Unfortunately, in today’s environment,  if we do not consider proper  documentation that satisfies evidence and value of our treatment  we leave ourselves vulnerable to the RAC auditors’ axe.  The best way to provide evidence and value is with peer reviewed functional tests and impairment measurements that eliminate subjectivity and doubt.  To accomplish this task, MediGraph PT Software includes more than 300 tests and measurements with references.  Are you using these tools? 

 As always, please call if I can assist you with this process.

Be well,

Tom Kane, PT

Stanford University Center for Health Policy: Model contractual language for medical

necessity. Developed at the workshop, Decreasing Variation in Medical Necessity Decision

Making. 1999 Mar 11-13; Sacramento (CA). Available at