Using functional questionnaires to get medicare compliance

Using Outcomes Questionnaires to get to Medicare Compliance

How to Open and Manage a Private Practice Physical Therapy Clinic

Adam Geril PT, DPTAdam Wood

Tim Richardson, PT

September 22, 2012Orlando, Florida

Using Outcomes Questionnaires to get to Medicare Compliance

• Describe the scope of the problem of documentation

• Introduce functional status questionnaires

• Link functional status to billing codes

• Describe 4 ways to link these together

• Video

Current Documentation Standards for Outpatient CPT coding

1) Skilled Physical Therapy Services

2) Medical Necessity or Medically Necessary Services

3) Progress


American Physical Therapy Association sponsored webinar on Medicare Compliance , February 13, 2010Daily note required for Therapeutic Exercise (CPT 97110)...

"Quadriceps strengthening into last 20 degrees of extension with mild manual resistance and proprioceptive cueing, 30 reps to fatigue, continues to decrease current extension lag and improve quality and duration of gait"

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“Treatment consists of manual therapy, 97140, to reduce swelling and scar formation; followed by passive, active assistive ROM exercise to improve ROM at the knee, 97110; quad sets, SAQ, and SLR to promote the efficiency of the quad contraction and promote quad control at the knee joint, 97112; and then by working on sit to stand transfers emphasizing knee flexion in sitting and equal weight distribution in sit to stand and stand to sit, 97530.”

Physical therapy Medicare Compliance e-mail newsletter. May 8th, 2012Daily note required for a ‘typical’ physical therapy intervention...

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Case Scenario: How to get from data to compliance



Belinda Holmes, Kerkering-Barberio, CPA, audit September 25th, 2010 Medicare Compliance SeminarPalmetto ,Florida

“I don’t know how you guys (physical therapists) have any time to treat patients and make any money!”

Medicare Benefit Policy Manual (280 pages)Section 220 (44 pages)

Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-

Language Pathology Services) Under Medical Insurance

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf




First Coast Service Options, Inc.

Local Coverage Determination

L29289 - Therapy and Rehabilitation Services

http://medicare.fcso.com/coverage_find_lcds_and_ncds/lcd_search.asp




220.3 – C“Documentation Requirements for Therapy Services: Results of one of the following four measurement instruments are recommended, but not required:

1) National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association

2) Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)

3) Activity Measure – Post Acute Care (AM-PAC)

4) OPTIMAL by Cedaron through the American Physical Therapy Association

If results of one of the four instruments above is not recorded, the record shall contain instead the following information ...”





3) Progress


Standardized Functional Status Measures1) Baseline2) Periodic 3) Outcome


1992 Questionnaire data is actively discouraged, it is too “subjective”.

2006 Hart white paper. Many academics, policy-makers & therapists feel that questionnaire data is too “soft”.

2007 Medicare “recommends” patient self-reports

2009 Jette study, 22% of PTs use “homegrown” patient self-report measures.

2011 Functional data included in 33 quality measures for Medicare Shared Savings Program (ACO)

Use of Standardized Outcome Measures in Physical Therapist Practice: Perceptions and ApplicationsJette et al, 2009

Only 48% of physical therapists used standardized measures of outcome, but...

> 90% believed they enhanced communication with patients

> 90% believed they helped direct the Plan of Care



• Disorders of the Arm, Shoulder, Hand (DASH)• Oswestry Disability Index (ODI)• Activities Balance and Confidence Index (ABC)• Lower Extremity Functional Scale (LEFS)• Patient Specific Functional Scale (PSFS)• Numeric Pain Rating Scale (NPRS)• Global Rating of Change (GROC)• Fear Avoidance Beliefs Questionnaire (FABQ)• OPTIMAL Scale• Focus On Therapeutic Outcomes (FOTO)

Various Therapy Metrics

Green – standardized self report questionnairesRed – Performance measuresBlue – Clinical Decision Rules





3) Progress


Mary is a 65 year old retired schoolteacher with a gradual onset of activity-limiting lower back pain. She has HTN 140/90, AODM (HbA1c 5.5%), cataracts, TKR right (2011), obesity (BMI 31) and takes Xanax for depression. She is not physically active.

Diagnosis: Lower Back Pain

Chief Complaint: “My back hurts with lifting and transferring my Mom and I’m afraid to kneel on my right knee because I’ve had a Total Knee Replacement”.

OPTIMAL score for kneeling 5/5 (unable)OPTIMAL score for lifting 4/5 (much difficulty)

When prompted, she answers the following: “I should NOT do activities which make my pain worse.”

Activity and Participation Limitation: “I’m caring for my mother but I may have to admit her to a Skilled Nursing Facility because I can’t physically help her anymore.”


Mary is a 65 year old retired schoolteacher with a gradual onset of activity-limiting lower back pain. She has HTN 140/90, AODM (HbA1c 5.5%), cataracts, TKR right (2011), obesity (BMI 31) and takes Xanax for depression. She is not physically active.

Diagnosis: Lower Back Pain

Chief Complaint: “My back hurts with lifting and transferring my Mom and I’m afraid to kneel on my right knee because I’ve had a Total Knee Replacement”.


When prompted, she answers the following: “I should NOT do activities which make my pain worse.”

Activity and Participation Limitation: “I’m caring for my mother but I may have to admit her to a Skilled Nursing Facility because I can’t physically help her anymore.”


“I’m afraid to kneel on my right knee because I’ve had a Total Knee Replacement”.





3) Progress


Use of Quality Indicators in Physical Therapist PracticeJette and Jewell, 2012

2,544 physical therapists surveyed...

Determine medication use 73%Measured cardiovascular response to exercise 40%Completed a standardized falls risk assessment 36%Completed a standardized functional status measure 33%Asked about tobacco use and advised to quit 21%Measured and followed-up with referral for BP 11%Measured standardized 10’ gait velocity 5.5%Measure Body Mass Index (BMI) 3.6%

...physical therapists may not see themselves as... primary care providers. Patient management strategies associated with these... services may be perceived as... burdensome.


Pertinent physical exam findings:

1) Stiffness in both hips (internal rotation ROM, usually measured prone with bubble inclinometer.

2) Pendulous abdomen with low force producing capacity (usually measured supine or sitting with a pressure biofeedback device).

3) Stiff, kyphotic thoracic spine (usually measured using modified Schober's test of trunk forward bending and sidebending).

4) Fear of movement, as noted. FABQ-physical activity = 14


Pertinent physical exam findings:

1) Stiffness in both hips - 97140

2) Pendulous abdomen with low force producing capacity – 97110, 97112

3) Stiff, kyphotic thoracic spine - 97140

4) Fear of movement, as noted - 97530


Drilling down from OPTIMAL Kneeling...

...can’t put on socks/shoes

...wears flip flops more often

...has stopped going to church as often

...feels less sociable

... is depressed


What are the “hard skills” of the physical therapist in 2012?

Assess functional status

Screening for pathology

Measuring vital signs



Symptom/Chief Complaint = LBP

Functional Status = can’t lift/squat/kneel. Fear of movement.

Activity/Participation Limitation = unable to fulfill role as caregiver, unable to live independently.

Therapeutic Exercise 97110 Therapeutic Activities 97530

Manual Therapy 97140 Neuromuscular Reeducation 97112

Modalities/Traction


Paper-based:1) Narrative notes (slide 3 & 4)2) Task-oriented Flow Sheets (slide 29)

Electronic Medical Records (EMR):3) Structured Data fields (slide 30 & 31)4) Natural Language Processing (slide 32 & 33)5) Video


Paper-based:1) Narrative notes (slide 3 & 4)2) Task-oriented Flow Sheets (slide 35)

Electronic Medical Records (EMR):3) Structured Data fields (slide 36 & 37)4) Natural Language Processing (slide 38 & 39)5) Video


Task-oriented Flow SheetKneeling on Foam unable unable Able to kneel 1’ on left with

manual stabilizationLeft x 1’Right x 2’

Left x 1’Right x 2’

Functional Reach, 3-way x1’ forwardx1’ left, too much trunk bendx1’right

x1’x1’x1’

x2’x2’x2’

x2’x2’x2’

x2’x2’X2’

Single leg Support, eyes open x2’ x2’ x2’ x2’ x2’

Single leg Support, eyes closed x2’, contact guarding to minimize postural sway

x2’, no contact guard x2’ x2’ x2’

Manual therapy to improve hip flexion in standing

Lateral right thigh x 5’Lumbar prone x 10’PROM hips in supine x 10’

Lateral right thigh x 5’Lumbar prone x 10’PROM supine x 10’

Lumbar prone x 10’PROM supine x 10’

Lateral right thigh x 5’Lumbar prone x 10’PROM supine x 10’

PROM hips in supine x 10’

Functional squat unable 10 reps, with breaks. Too much trunk flexion. Too much hip/knee valgus.

10 reps, no stopping. Too much knee valgus.

20 reps, with breaks 20 reps, no stopping

Four Square Stepping 4 x 1’ 4 x 1’ 4 x 1’ 4 x 1’, 2 sets 4 x 1’, 2 sets

Tandem walking 40’ 2 x 40’ 2 x 40’ 3 x 40’ 4 x 40’ with gaze challenges

5 x 40’ with gaze challenges

Abdominal muscle pressure biofeedback with device, supine and sitting

Supine x 1’, tends to hold breathSitting x 1’, tends to hold breath

Supine x 1’Sitting x 1’, tends to hold breath

Supine x 2’Sitting x 2’, tends to hold breath

Supine x 2’Sitting x 2’Standing x 1’

Supine x 2’Sitting x 2’Standing x 1’


Pressure biofeedback score of abdominal force producing capacity, sitting/supine

Schober’s test for spinal ROM

BP measure. Referred?

“Can’t kneel/squat to clean home or make the bed” (ICF qualifiers and modifiers, 0-9)

“Can’t lift/transfer my husband” (ICF qualifiers and modifiers, 0-9)

Hip Internal Rotation ROM score

OPTIMAL Kneeling score

Therapeutic Exercise 97110

Manual Therapy 97140

Therapeutic Activities 97530

Neuromuscular Reeducation 97112

Modalities/Traction

Visit 2 Visit 3 Visit 4Evaluation Discharge

Evaluation 97001

BP BP BP BP

Schober’s test

OPTIMAL score

Knee AROM & PROM

Fear Avoidance Beliefs (FABQ score)


Visit #1: ““I’m afraid to kneel on my right knee because I’ve had a Total Knee Replacement”.


Visit #2: “97112 (x2) pressure biofeedback to improve abdominal force-generating capacity to facilitate lifting/transferring her husband.”

Visit #3: “97530 (x2) challenging/educating Mary’s fearful attitudes about kneeling/squatting. 97110 performing simple non-painful knee/hip flexion tasks that she has previously avoided.” 6


Natural Language Processing


Natural Language Processing




3) Progress


Video documentation

“As required by the Middle Class Tax Relief Jobs Creation Act of 2012, CMS proposes to implement a claims-based data collection process to gather data about patient function for patients receiving outpatient physical, occupational, and speech therapy services.

Therapists would be required to report new codes and modifiers on the claim form that reflect a patient’s functional limitations and goals at initial evaluation, periodically throughout care and at discharge.

This data is for informational purposes and is not proposed to be linked to reimbursement.

This reporting system is proposed to be implemented on January 1, 2013. Claims will be processed during the first 6 months until July 1, 2013 regardless of the inclusion of the functional limitation codes.

Beginning July 1, 2013 all claims must include functional limitation codes to be paid by Medicare.”


• Describe 5 ways to link functional status to billing codes

• Important because functional status is an important, if overlooked, aspect of the patient experience in healthcare.

• Narrative, especially handwritten, is inadequate and embarrassing in the 21st century to reflect physical therapists’ skill and abilities.


Thank You!

How to Open and Manage a Private Practice Physical Therapy Clinic

Adam Geril PT, DPTAdam Wood

Tim Richardson, PT

September 22, 2012Orlando, Florida

Self Improvement

Using functional questionnaires to get medicare compliance