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

The Waiting Room
10/26/2011 10:51:00 AM
Please No Waiting.
 
From the patients' point of view, sitting in the waiting room for treatment is one of the most disliked components of any medical visit.  This phenomenon is especially true for patients that are receiving physical therapy.  Why?  Most people visit the doctor's office once every 2-3 months and the wait is softened by the interval of weeks between visits.   With PT the visits are usually 2-3 times per week.  The best treatment can be seen as less worthy by a patient that sits idle in the waiting room. 
 
There are a few suggestions that can help to remedy this problem:
 
    1.  Do not over-schedule patients.
    2.  Staff properly.  Many offices make the mistake of employing sufficient staff to handle the slow periods.  This policy is employed to reduce costs and prevent idle time.  In our practice, our philosophy was to staff up for the busiest periods, understanding that there will be times when personnel are under utilized.  Why did we take this approach?  Colloquially stated, "The bridge does not break at 3 AM; it breaks at rush hour.  Build the bridge for when traffic is heaviest."
    3.  Use a HIPPA compliant 'Sign in' sheets to avoid taking patients out of order.  If a patient is intentionally taken out of order, explain to the waiting patient the reason, most common of which is equipment specific.
    4.  Have the patient complete outcome questionnaires while waiting.
    5.  Involve the receptionist in managing patient flow.  This step is important because the patient's often believe that the front office is ignoring them.  For example, upon arriving in the office, the receptionist should greet the patient:
            Receptionist:  "Good Morning Mr. Jones.  I will tell the staff that you are here." 
 The receptionist will then will buzz the treatment area telling a clinical staff member that Mr. Jones has arrived.  This simple act of courtesy acknowledges the patient, lets him know that the staff has been alerted to his presence, and enables the staff to make special provisions for treatment (traction room, whirlpool, etc.).  It also disarms the patients'  fear that he or she is being ignored.
    6.  Use the MediGraph appointment reminder to call and email patients of their appointment time.  This utility not only prevents missed visits, it helps patients maintain their schedule as well. 
 
Are we skilled practitioners? Yes.  But we should never loose sight of the fact that we are also business owners/operators.  Satisfied patients (customers) will grow your practice.  In my experience, the best intervention can be rendered worthless if we ignore the idea that our patients are also our customers.  Do not get fooled into believing that because we do good we should be appreciated for our skills.  In our practice we treated every patient as though we were privileged to have them.  Why?  Because we were privileged to have them.  Accordingly, they would return to our office for future incidents, and refer friends and family to our offices as well. 
 
Regards,
Tom Kane, PT     
Physical Therapists as Expert Witness. Perspective, Fees, and Fears
10/6/2011 1:59:00 PM
I often have receive calls from MediGraph Subscribers wanting to discuss the subject of expert witness testimony.  Callers want to learn of my experience in this area to help prepare for this task and address the uncertainty surrounding this responsibility.  Because this area of PT often goes un-addressed I will present some thoughts from my experience with appearing as an expert witness, including the appropriate fees. 
 
As physical therapists it is reasonable to assume that we may have to testify in a proceeding involving a patient.  This statement is especially true when treating work related injuries, personal injury patients (motor vehicle accidents, slip and falls, etc.), or other injured patients where liability is an issue.  Having appeared as an expert witness and having coached others that have appeared, testifying under oath can be intimidating on the first encounter.  The uncertainty of not knowing what to expect is the most disturbing aspect of this task for those that will appear for the first time.
 
For clarity, the party that is suing (usually the patient) is the plaintiff.  The party being sued (usually the insurance company) is the defendant.   When appearing as an expert, one side  is your ally and the other is your adversary.  Usually, but not always, the party that pays for your appearance is your ally, as they believe your testimony will support their position.  The goal of the attorney that is your ally is to establish your credibility.   The goal of the attorney that is your adversary is to destroy your credibility.  Sadly, the authenticity or factual nature of the case is often not as important as counsels'' ability to make you appear  believable or unbelievable.  For example, in one of my first appearances as an expert witness I was testifying on behalf of a patient that I treated (the plaintiff) three years prior to my testimony (it took three years for the case to be heard in court).  The patient was asked in a prior deposition, "Mr. X, how many times did you receive traction or exercise for your condition?"    This patient replied, "I don't remember exercising or traction."   As stated previously, the patient, a laborer, was treated three years prior to his deposition.  He could not recall receiving therapeutic exercise or traction.   When my testimony was rendered, counsel asked me:
 
Counsel:  "Are these your records?" 
TKane:     "Yes."
 
Counsel:  "Is this your bill?" 
TKane:     "Yes"
 
Counsel:   "You claim that you provided traction and therapeutic exercise to Mr X on 12 occasions." 
TKane:     "Yes."
 
Counsel:  "But under deposition Mr. X denied ever receiving those treatments.  Are you certain that you provided these treatments?"  
TKane:    "Yes."
 
Consel:  "How can you be sure when the patient has no recollection what so ever?"
TKane:   "Because my documentation reflects those treatments." 
 
Counsel:  "So, because these treatments appear in your notes, we are supposed to believe that you gave these treatments even though Mr. X states he cannot remember what traction or therapeutic exercise is?" 
TKane:   "Yes."
 
At this point, plaintiff's attorney (the patient's counsel) objects, stating that Mr. X is not an educated man, he is not a physical therapist, this treatment was rendered three years ago, to ask Mr. Kane to asses Mr. X's ability to recall, blah, blah, blah.  The point here is to illustrate that opposing counsel will attempt to discredit your testimony and destroy your credibility no matter how truthful your statements or intentions.  This kind of tactic is especially true in a jury trial where  the members of the jury are far more impressionable than an arbitration hearing before a judge or panel, where the audience is not so easily swayed by such tactics.  After gaining experience, my answers to this type of question changed.  I would respond truthfully but with greater understanding of how this portion of expert witness testimony works, preventing myself from falling into that well placed trap.  This is just one example of what expert witness testimony experience.  There are many others, including those surrounding FCE testimony.
 
Regarding fees for expert witness appearances, my fees varied depending on the situation.  There are a few variables to consider, including:
 
  1. How complicated is the case?  Testimony in a straight forward history (fracture, post surgical rehab, etc.) will require less preparation time than a more complicated course of treatment.  Your prep time should be reflected into your cost.
  2. Where will this testimony occur?  Fees vary based upon such variables as a video deposition in my office, in the attorney's office, before an arbitration panel, or before a jury?
  3. How much will it cost to pay someone to handle my patient load when I am absent?
 
Generally, the minimum fee that I charged for my testimony was $750.  For a Deposition in my office I charged $750-$1000.  For a deposition in an attorney's office I would charge $1000-$1250.  For a jury trial appearance I will charge $1500-$1750.  Jury trials usually involve more delays and waiting.  This degree of uncertainty from a time perspective when compared to the other areas presented above should be considered.
 
I hope this brief overview proves helpful.  As with other issues from MediGraph Subscribers, my consultation in this area as well as any other areas is free of charge.  Feel free to call.
 
Regards,
Tom Kane, PT
New CCI Edits Effective October 1, 2011
10/4/2011 4:40:00 PM
The most recent version of CCI edits from Centers for Medicare & Medicaid Services (CMS) went into effect on October 1, 2011.  As you may know, CMS'  goal for the Correct Coding Initiative (CCI) is to promote  correct coding nationally and control improper coding that leads to inappropriate payment in Medicare Part B claims.   CCI edits are intended to ensure the most comprehensive groups of codes are billed instead of the component parts. In addition,  CCI edits check for mutually exclusive code pairs. The unit-of-service edits determine the maximum allowed number of services for each HCPCS code.

The CCI edits fare available from the CMS website at  https://www.cms.gov/NationalCorrectCodInitEd/

PT's and OT's in private practice as well as physician owned therapy clinics should choose NCCI Edits--Physicians.

Regards,

Tom Kane, PT

The Difference Between PT and Ordinary Medicine
10/2/2011 6:59:00 PM
I had a conversation with a PT educator this week.  Instead of posting the normal practice update, I wanted to present the topic of that discussion.

The very suggestion that PT is different from regular medicine is offensive to some physical therapists.   Considering the drive toward DPT programs, the goal to elevate the perception of our profession’s status, and the attempt to mainstream all medicine into a manageable illness based model facilitates an easy understanding why suggesting that we are different from ordinary medicine is offensive.  I disagree.  I separate physical therapy from ordinary medicine willfully and eagerly.

I refer to traditional healthcare as ‘Sick care’.  The medical paradigm, the Western model of medicine is management of the disease.  The pharmaceutical model of medicine that is practiced today is the vertical approach to medicine; one disease one drug. For example, first line treatment in the pharmaceutical model for hypertension is to prescribe beta blockers.  In nature, there is no such thing as a beta blocker deficiency.   Beta blockers do not restore health.  This intervention treats a symptom.  Beta blockers’ side effects include increasing the risk of insulin resistance and Type II diabetes.  Beta blockers require ongoing monitoring and dependence.   They often contribute to heart failure by blocking the beta receptor sites in the heart.  But, they do reduce blood pressure.

PTs treat symptoms.  But such symptomatic treatment is a means to an end not as the end or goal of treatment.   The goal of physical therapy is to improve or restore function.  When we treat a patient, they do not need us for the rest of their lives.  Our goal is to release the patient from treatment.  When we treat patients, we do not need to have follow up visits to look for side effects.  Our goal is patient independence and the only side effects that our interventions produce are independence, greater function, greater self reliance, and the desire that patients are no longer in need of our services.  It’s true my colleagues.  PT is different from ordinary medicine.   We do not practice ‘Sick care’.   And I am proud of it.    

Regards,

Tom Kane, PT