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

The ‘Disablement’ Model Progress Note: A RAC Auditor’s Nightmare
7/30/2011 11:47:00 AM

Dear Subscribers:

We at MediGraph continue to emphasize the importance of RAC sensitive documentation.  Our preventative approach is designed to protect you from the RAC auditors’ goal of extracting a refund from you.   RACs do not care if the patient got better!  RACs only care if your documentation meets their standards.  You could be the best therapist in the world and it would not matter to an auditor.  Unless we understand that the RACs purpose is to obtain a refund for past services rendered we are missing the boat.  Please consider these SOAP Note suggestions to emphasize disablement (loss of function):

Subjective:  When using the MediGraph Daily Note Editor, the third choice in the Subjective menu is ‘Functional Complaints’.  Functional complaints are also listed in the “Area Specific” drop down menu. The ‘Subjective’ entry of your progress notes should include personalized patient functional complaints.  For example: Mr. Smith states, “He has pain and weakness in his knee (impairments).  He also states that he cannot get up from a chair independently, and that he cannot walk more than 10 feet once standing (functional disablement).”   If Mr. Smith had pain and weakness, but did not have decreased function, the medically necessary component of your treatments will be challenged and you may be forced to refund the fees for Mr. Smith’s treatment (all of the fees).   

Objective:  Please Measure Something!   MediGraph is the only program available that integrates hundreds of standardized and peer reviewed measurements of impairment and function within the documentation program.  Use these objective tools to substantiate the patients impairments and  functional deficits.  For example, Mr Smith has knee complaints of weakness, pain, inability to transfer, inability to ambulate more than 10 feet.   Measure Mr. Smith’s loss of strength (an impairment), preferably with a hand held dynamometer (HHD).*    However, impairment measurements are not sufficient to satisfy the need for intervention.  To justify treatment, a functional deficit must be present (inability to transfer, inability to walk).  Use a functional test to reveal Mr. Smith''''s disablement-functional deficit.  Have Mr. Smith perform the Tinnetti (balance and initial gait testing), the TUG, or any functional test to demonstrate that his functional ability has been objectively assessed.   Also, employ the functional outcome questionnaires in MediGraph (OPTIMAL, Lysholm Knee Rating, Musculoskeletal Function Assessment, etc.).  

Assessment: Obviously, the assessment portion of the note will address the patient goals.  However, many therapists do not use the assessment portion of the SOAP to update the diagnosis, and to link the updated diagnosis to the patients’ functional improvements.   For example, “Mr. Smith HHD reveals strength gains of 20% (impairment improvement), which has translated into increased ambulation from 10 feet to 20 feet (functional improvement).  Mr Smiths performance on the TUG test reflects a functional improvement of 25%.”

Plan: The Plan portion of the SOAP note is primarily employed to alter the treatment plan.  The plan should be updated when new findings are discovered, expected, and to revise goals as the result of these findings.  The Plan portion of the note does not need to be completed on a daily basis. 

All the tools to outsmart the RACs are at your disposal in MediGraph.  All of the components mentioned above are included in your subscription.  Our goal is to assist you with using the software to protect you from those predators that are only rewarded by obtaining a refund from you.   Please call with any questions.

Be well,

Tom Kane, PT

Medicare Legal Documentation Questions
7/27/2011 10:38:00 PM
Dear Subscribers:

New MediGraph subscribers often ask questions that are related to Medicare standards and the legality of specific functions that relate to documentation.  Three of the most frequently asked questions are presented below.

Question:  Can I edit my notes after the day of treatment?

Answer:  Section 220.3 states, “Dictated Documentation. For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date.

Question:  Is it legal to write a progress note at a later date?

Answer:  Section 220.3 states, “Dates for Documentation. The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the Progress Report or Treatment Note refers.”
Question:  How do I prove that a skilled professional care was required?

Answer:  "To determine whether a service is skilled, and therefore coverable, the new regulations direct decision-makers to review accepted standards of clinical practice and to consider whether a professional is needed for the service to be safe and effective for the particular beneficiary.”

If we interpret this last answer with a most literal perspective, the ability to improve the patient’s condition becomes secondary to proving that skilled care was required.   If we are honest, we will admit that these perfunctory tasks are not designed to improve patient care or outcomes.  They are designed to reduce the care rendered in an attempt to save money.  A few software vendors present the documentation changes that are taking place in Medicare as though they are desirable.  If we were accountants, not therapist, I would agree.  We at MediGraph choose not to sugar coat this issue.  We comply with the documentation standards because we are forced to comply.  We address this matter openly, with the direct attention that it deserves.  In the near future, an upgrade of the program will take evidence based medicine to the next level, automatically providing intervention references that are diagnosis specific.  For example, if you choose to provide transverse friction massage for lateral epicondylitis, a peer reviewed reference will accompany the intervention.  We will guide through the Medicare requirement maze so that you can do what you do best; treat the patient.


Tom Kane, PT
Charging for Missed Appointments
7/25/2011 11:47:00 AM
Good Business and Good PT are Fully Compatible
I would like to share a discussion that occurred with a MediGraph subscriber regarding charging a patient for a mixed appointment.
Last week I received a call from a subscriber wishing to discuss the merits of charging  patients for missed appointments.  The therapist, who was in favor of charging for missed appointments, was in disagreement with his front office.  I told this subscriber, "You should charge for the missed appointment if you never want to see the patient again."   Allow me to explain.
Creating good will among our patients is a vital component to building a successful PT practice.   In our PT group we have received many referrals from former patients that were pleased with our facilitiy.   Also, we have had many referrals of patients that were unsatisfied with treatment from other PT facilities.    Were these patients that switched from other facilities to our office dissatisfied with their intervention?  Usually not.  Most patients do not know the difference between good care and poor care.  Those patients that transferred to our office from other facilities switched because they did not like how they were treated as people. 
My perspective in these matters is based upon successful business practices.   In addition to viewing injured people as patients, I always saw patients as customers.   In many PT circles, we have viewed elevating our profession standards to be in conflict with business.  This mistaken belief is often promulgated by academic types that have never operated a successful physical therapy office.   Charging for a missed appointment is an example of such backward thinking. 
Punishing the patient for a missed office visit is a poor practice that dismisses the therapists' complicity in this matter.  Our offices were proactive in this situation.  We called our patients a day in advance to remind them of their appointment.  Many patient visits were saved by this task.  Patients that potentially would have missed an appointment would reschedule in advance.  This approach also prevents the "Bad Will" that can occur when attempting to collect a penalty fee for a missed appointment.
Today, the task of calling patients in advance has been eliminated for MediGraph subscribers.  The MediGraph Appointment Manager calls the patient, sends them an email and a text message reminding them of their next appointment.  This feature saves time, money, and avoids the conflicts that can occur with missed appointments.     
Be well,
Tom Kane, PT
Second Quarter RACs Capture $592.5 million
7/18/2011 6:13:00 PM
The June report from The Centers for Medicare & Medicaid Services (CMS) has been released.  In the first half of 2011 RAC audits have captured $592. 5 million in refunds from medical providers.   At this pace , RACs will collect $1,850 billion in refunds for 2011.   Realisitcally, the $1.850 billion is a low estimate because RACS are gaining efficiency from their experience.  The greater efficiencies have resulted in a steady increase in refunds.  In each quarter reported, the RACs collect more than the prior quarter. The most problematic area for providers remains proving medical necessity for the treatment rendered (http://www.cms.gov/Recovery-Audit-Program/Downloads/FFSUpdate.pdf).
Throughout the MediGraph blog and in occasional emails, we have continued to emphasize the importance of establishing the medical necessity of treatment.   We have stressed the importance of using the impairment model of physical therapy to support the disablement model.  The impairment model (ROM, strength, pain, etc.) will not stand alone as justification for intervention.   The disablement model must demonstrate that the patient has a functional loss that is verified by objective assessments (functional tests like the 6 Minute Walk, Timed Up and Go, and peer reviewed outcome questionnaires such as OPTIMAL, Lysholm Knee Index, etc.).   All of the tools that you need to prevent a RAC from picking your pocket are contained in MediGraph.  These procedures consume time but they are not difficult to perform.  If you are not using these tools, start today.  If you need assistance or would like to discuss this matter, please call.  
Tom Kane, PT
MediGraph Software 
Tools used by RACs to Audit Records
7/7/2011 12:22:00 PM
Understanding the resources available to Medicare Random Audit Contractors (RACs) allows physical therapists to initiate measures that will assist with preventing audits and respond properly when an audit occurs.  The number of acronyms for the tools available to RACs is large and growing.  The current list includes:    
  • Raw data - RAC databases, routine CMS RAC Data Warehouse downloads, industry trends;
  • Outcome reports - CERTs(1), OIG(2), PEPPER(3), GAO(4), QIOs(5);
  • Industry experience and information - AAHAM, AHA, AMA, AAASC, JCAHO, JCAHACO;
  • Policy/rules and regulations(7) - LCDs, NCDs, CRs(8), IOMs, MLN; and
  • CMS programs - ZPICS(9), DOJ(10), vulnerabilities reports(11), carriers, FIs, MACs.
What does all this mean?  It means that RACs have become an unbridled extension of government bureaucracy that has one goal; obtaining a refund from medical providers.   These tools give RACs the ability to design criteria that can change on an ongoing basis.  For physical therapists there is good news and bad news in relation to this process. 
The good news for physical therapy is that on a comparison basis, PT will face fewer variations in the criteria used by RACs when compared to other disciplines (multi-discipline medical practices, out patient surgical units, private outpatient surgical suites) that will be forced to anticipate audits on numerous intervention levels.  The bad news is that auditing PT records is easier for a RAC because they can focus on the blatant omissions that currently occupy many therapists'''' documentation. 
Many of the MediGraph subscribers that I speak with do not utilize the RAC prevention tools in the software. The vast majority of therapists searching for documentation software are not currently using the proper documentation measures.   Most PTs continue to emphasize and document the impairment model instead of integrating the impairment model into the disablement model.  Many therapist fail to measure impairments.  Those that do measure impairments fail to demonstrate/measure that the impairment results in a functional disability (gait or balance problems, self care disability, etc.).   Many therapist do not use the published outcome questionnaires (72 of these instruments are in MediGraph).  All of these RAC prevention tools are at your disposal at no cost. With proper billing they are your defense against  a RAC refund. 
If you have any questions regarding how to implement these tools, please contact Dave Naples at extension 211, or Tom Kane at extension 210.  As always, the education and customer support are included as part of your subscription  at no cost.
Be well,
Tom Kane, PT
MediGraph Software