Should I Hire a Physical Therapist?

Hiring a physical therapist to work in a chiropractic office can be a wonderful experience or it could turn into a nightmare. A physical therapist who is working under your (the DC) clinical supervision relies on your clinical expertise to make patient healthcare decisions. This now requires that you put focus into another arena than just the chiropractic arena. Are you ready to take on another project? It will require you to work more (at least in the beginning) or hire someone else to oversee this part of your practice. You will be responsible to educate the physical therapist what your position is on proper physical therapy documentation treatment guidelines. I will now review with you my recommendations.

Let’s begin with general guidelines and then we’ll discuss the specific physical therapy Evaluation & Re-Evaluation CPT® codes. The overall goal for your therapist should be to get the patient to return to the highest level of function realistically attainable and within the context of the presenting problem. Covered services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the patient’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency, and duration. There must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time-based on the physician’s assessment of the patient’s rehabilitation potential.

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PT Insurance Coverage

Physical therapy is only covered when it is rendered under a written treatment plan and must address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency, and duration. The therapist must document the patient’s functional limitations and therapeutic short and long term goals in terms that are objective and measurable. Physical therapy is not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist. It is not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate.

Physical therapy is not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected. The skills of the Physical Therapist are not required to maintain function. Limited services may be considered reasonable and necessary to establish and assist the patient with the implementation of a maintenance program. No more than 2-4 visits are considered medically necessary to establish a maintenance program. Physical therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the Physical Therapist. Normally, visit frequency would decrease as the patient’s condition improves. PT services which are duplicative of other concurrent rehabilitation services are not covered.

PHYSICAL THERAPY EVALUATIONS – CPT® Code 97001

Physical Therapy Evaluations are required prior to begin therapy for determining the medical necessity of initiating rehabilitative services. Patients must exhibit a significant change from normal functional ability to warrant an evaluation. Factors that influence the complexity of the evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient’s overall function and health status. The evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. If the patient presents with multi-system involvement and/or multiple site involvement, all areas/conditions should be assessed at the initial evaluation (i.e., cervical pain and knee pain; low back pain and rotator cuff; cervical pain and low back pain).

Only 1 evaluation code should be used and all areas assessed. Therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, and disability; the living environment; and the social supports (i.e., the potential for effecting an improvement in the patient’s functional ability). Initial evaluations may be covered even when it is determined that a skilled level of service is not required if the patient’s condition showed a need for the evaluation, even if the goals established by the plan of care are not realized.

The patient is not eligible for further treatment if it has been determined that he/she is at maximum therapeutic potential and further therapy would not result in any significant improvement, such as may be the case with many chronic conditions. Initial evaluations from other therapy disciplines performed on the same beneficiary may also be covered, provided the referral, evaluation and plan of treatment are not duplicative.

Documentation Requirements:

The written evaluation must demonstrate the patient’s need for skilled therapy based on functional diagnosis, prognosis, and positive prognostic indicators. The therapist must have an expectation that the patient will achieve the established goals. Initial evaluations must contain the following information:

• Evaluations without any of these elements will be non-covered
• Reason for referral and specific treatment requested
• Diagnosis and functional condition/limitation being treated and onset date.
• Applicable medical history, medications, comorbidities (complicating or precautionary information)
• Primary subjective complaint
• Mechanism of injury (if applicable)
• Previous diagnostic imaging/testing
• Prior level of function- be specific (mobility home and community, employment, school, etc.)
• Prior therapy history
• Baseline evaluation data must be objective and measurable and include all applicable areas. The following list is not intended to be all-inclusive, but to be used as examples: cognition, vision/hearing, vascular signs, sensation/proprioception, edema, posture, active range of motion/passive range of motion, strength, pain, coordination, bed mobility, balance (sit and stand), transfers, ambulation (level and elevated surfaces), orthotic/prosthetic devices, wheelchair use, durable medical equipment (using or required), activity tolerance, wound description (including incision status), special tests (include the name and scores), architectural/safety considerations, requirements to return to home, school, and/or job.

Treatment Plan

The treatment plan is meant to serve as a guide to patient care. Revisions in the plan are expected to be documented as the clinician responds to changes in the patient’s status. Revisions to the plan of care are expected when functional progress is not achieved within a reasonable period of time. The plan of care should include:

• the specific treatment strategies (i.e., specific modalities to be used, a specific type of activities and exercises
• the areas of the body to be treated
• frequency of treatment with the specific number of visits per week, not a range (i.e., 2-3 times per week)
• duration
• patient instruction/home program
• short term goals, which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment
• long term goals, which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment
• signature and credentials of the therapist performing the evaluation.

PHYSICAL THERAPY RE-EVALUATIONS – CPT® Code 97002

Re-evaluations are covered and may be billed as a separate charge only if the documentation shows significant change in the patient’s condition that supports the need to perform a formal re-evaluation of the patient’s status. When a patient exhibits a demonstrable change in physical functional ability, a re-evaluation is covered to reestablish appropriate treatment goals and interventions.

Reassessments are considered a routine aspect of intervention and are not billed separately from the charge associated with the intervention. Continuous evaluation of the patient’s progress is a component of the ongoing physical therapy services. Re-evaluations are not routinely covered for purposes of updating the plan of care.

Documentation Requirements:

The components of the re-evaluation and the documentation requirements are the same as the initial evaluation, but are focused on assessing significant changes from the initial evaluation or progress toward treatment goals.

Dr. David Pinkus is a senior consultant with Target Coding and President of DBP Audit Consulting. Dr. Pinkus will be a featured speaker at the 2007 Chicago National Convention and Expo on September 28-30, 2007. For more information please visit www.chicagonationalconvention.com.

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