RE: One- on- One Treatment for Medicare vs. Non-Medicare patients

[Guest guest]

,

Please do not take this as a personal affront because it is not meant that

way but in short the answer to your last question is yes and intention is

irrelevant. I have sadly heard others try to spin various self serving

perspectives on this issue in an effort to cloud the picture. CPT coding is

well defined and payer neutral making the payer an irrelevant issue except

with respect to the " 8 Minute Rule " which is a purely CMS invention. It can

be effectively argued that with respect to payers other than Medicare the

coding expectations with respect to " one to one " procedures could be held to

an even higher standard whereby anything less than 15 minutes does not meet

the " billable " threshold. While I am aware that this may not be the

generally accepted practice in the current environment that alone does not

make it correct or acceptable if it were to come under scrutiny by a payer.

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark F. Schwall, PT

Future Physical Therapy, PC

1594 Route 9

Unit 2

Toms River, NJ 08755

Fax

Skype mfschwall

President

New Jersey Society of Independent Physical Therapists

2123 Route 35

Sea Girt, NJ 08750

From: PTManager [mailto:PTManager ] On Behalf

Of scott hankins

Sent: Monday, April 14, 2008 7:21 PM

To: PTManager

Subject: One- on- One Treatment for Medicare vs. Non-Medicare

patients

Group,

I know this has been discussed in the past, but it has become a matter of

discussion between my partner and I. My partner is not a PT and looks at

numbers only, not numbers and patient care like me.

Here is the issue- During doubled up treatment slots when we are treating

under the " one on one " rule from CMS, meaning the individual times equal the

total treatment time for both patients, is it mandatory to apply this same

CMS rule to non-Medicare patients?

It seems ethical to apply the rule for both patients, but my partner wants

to " push the envelope " and not apply the one on one rule to the non-Medicare

patients for the sake of the bottom line. Thus I would be coding my units as

if I was seeing both patients on an individual basis. Am I being

unintentionally fraudulent with the non-Medicare contractors?

Thanks in advance,

Hankins, PT/President

Synergy Therapies, LLC

[Guest guest]

Hi, -

Thanks for the post. Yes, you are.

" One-to-one " is not a CMS rule, but it is part of the Current Procedural

Terminology (CPT) Codes. Under HIPAA, there is only one common set of

procedural descriptors, and it is the CPT Codes. The PT profession has

representation on the CPT Code committee.

If you bill XYZ Mutual, or any other insuror, for CPT Code 97110,

Therapeutic exercise, you are certifying to them that you were 1:1 with the

patient for that time. The " >8<23=15 minute rule " is Medicare's, however.

In teaching accounting, we teach a principle called " contingent liability " .

When we pay our bills and count our money, we need to also account for the

bills which " might " occur. If someone " pushed the envelope " in his billing

practices, he needs to account for the amount he might have to give back to

Medicare... extrapolated to his entire tenure as a Medicare contractor...

plus double or treble that amount as fines. Bad Juju.

So, I'd encourage any pratitioner or partner to understand that " doing it

right " really is the best business policy. XYZ Mutual may not catch you,

but it's still fraud to bill 97110 to anyone when you're not one-to-one with

the patient. If you were in Florida, any licensed employee is required to

report you if they know what you did. Many other states have similar

" mandated reporter " provisions in their laws.

Hope this helps!

Dr. Dick Hillyer

Dr. W. Hillyer,PT,DPT,MBA,MSM

Hillyer Consulting

Cape Coral, FL 33914

_____

From: PTManager [mailto:PTManager ] On Behalf

Of scott hankins

Sent: Monday, April 14, 2008 7:21 PM

To: PTManager

Subject: One- on- One Treatment for Medicare vs. Non-Medicare

patients

Group,

I know this has been discussed in the past, but it has become a matter of

discussion between my partner and I. My partner is not a PT and looks at

numbers only, not numbers and patient care like me.

Here is the issue- During doubled up treatment slots when we are treating

under the " one on one " rule from CMS, meaning the individual times equal the

total treatment time for both patients, is it mandatory to apply this same

CMS rule to non-Medicare patients?

It seems ethical to apply the rule for both patients, but my partner wants

to " push the envelope " and not apply the one on one rule to the non-Medicare

patients for the sake of the bottom line. Thus I would be coding my units as

if I was seeing both patients on an individual basis. Am I being

unintentionally fraudulent with the non-Medicare contractors?

Thanks in advance,

Hankins, PT/President

Synergy Therapies, LLC

[Guest guest]

,

The Centers for Medicare & Medicaid Services do not

develop the CPT codes. They are developed by the

American Medical Association. These CPT codes that are

timed and require direct one-on-one intervention by

the therapist apply to Medicare and non-Medicare

patients alike. The payer does not matter. What

determines what can be billed to each patient is

dependent upon what the therapist or assistant is

doing with each individual patient. If you had 2

non-Medicare patients being seen by one therapist and

that therapist went back and forth between the 2

patients providing incremental one-on-one therapeutic

interventions to each patient, the total number of

units that could be billed to each patient would be

dependent upon the amount of time the therapist

actually spent with each patient. If you wouldmlike to

discuss further, please contact me directly.

Rick Gawenda, PT

President, Section on Health Policy & Administration

APTA

--- scott hankins wrote:

> Group,

>

> I know this has been discussed in the past, but it

> has become a matter of discussion between my partner

> and I. My partner is not a PT and looks at numbers

> only, not numbers and patient care like me.

>

> Here is the issue- During doubled up treatment

> slots when we are treating under the " one on one "

> rule from CMS, meaning the individual times equal

> the total treatment time for both patients, is it

> mandatory to apply this same CMS rule to

> non-Medicare patients?

>

> It seems ethical to apply the rule for both

> patients, but my partner wants to " push the

> envelope " and not apply the one on one rule to the

> non-Medicare patients for the sake of the bottom

> line. Thus I would be coding my units as if I was

> seeing both patients on an individual basis. Am I

> being unintentionally fraudulent with the

> non-Medicare contractors?

>

> Thanks in advance,

> Hankins, PT/President

> Synergy Therapies, LLC

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

________________________________________________________________________________\

____

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[Guest guest]

,

I agreed with CMS Federal rules and regs.? since those can take you into audits,

suspensions etc.? However, I don't agree with the private insurances.? Based on

you contract, realize that?the?insurance companies really shouldn't have any

say, on clinical boundries or patient care- that is accurate, based on our

efforts, professional autonomy or the bottom line.? They interested in their

bottomline.? So you if play their game (and you don't have too-cash based

services) you have to realize that your efforts need to be well merited and paid

for.? SInce they may not pay you for this (around us some pay a flat fee- no

time parameters) we have to assure that your bottom line is protected.? In our

clinic (with the flat rate) we get the patient better fast and move them to our

wellness program.? Some therapists can get people better faster and these guys

will save you money based on the result.? Depending on the time units and how

many the insurance pays you can certainly bill as charged.??Do realize that the

insurance situation is not something that you show aggreements with because

those guys are really not on our side.? Keep your ethics?in and realize that

they will most likely? NEVER see a rise their fees, irrespective of inflation,

cost of living increases etc.? There are very few commodities that can do that

and you are the one dropping dollars out you pocket.? They make money simply on

the fact that they don't increase their fees on the subjects above.? Its

criminal, but its our choice.

Best wishes

Vinod Somareddy, DPT???

One- on- One Treatment for Medicare vs. Non-Medicare

patients

Group,

I know this has been discussed in the past, but it has become a matter of

discussion between my partner and I. My partner is not a PT and looks at numbers

only, not numbers and patient care like me.

Here is the issue- During doubled up treatment slots when we are treating under

the " one on one " rule from CMS, meaning the individual times equal the total

treatment time for both patients, is it mandatory to apply this same CMS rule to

non-Medicare patients?

It seems ethical to apply the rule for both patients, but my partner wants to

" push the envelope " and not apply the one on one rule to the non-Medicare

patients for the sake of the bottom line. Thus I would be coding my units as if

I was seeing both patients on an individual basis. Am I being unintentionally

fraudulent with the non-Medicare contractors?

Thanks in advance,

Hankins, PT/President

Synergy Therapies, LLC

[Guest guest]

,

You and your partner are not the only ones having this conversation!

Read your insurance contracts (with Aetna, United, etc.)

They all have (or should have) a standard non-discrimination clause

that states that you cannot treat their beneficiaries (your patients)

different from any other beneficiary.

You cannot routinely treat Medicare one-on-one while allowing United

or Aetna patients to perform unsupervised exercise (by themselves or

with an aide).

You may not be 'fraudulent' to Medicare but you would be violating the

anti-discrimination clause of the contract you signed with the private

insurance company.

Tim , PT

>

> Group,

>

> I know this has been discussed in the past, but it has become a

matter of discussion between my partner and I. My partner is not a PT

and looks at numbers only, not numbers and patient care like me.

>

> Here is the issue- During doubled up treatment slots when we are

treating under the " one on one " rule from CMS, meaning the individual

times equal the total treatment time for both patients, is it

mandatory to apply this same CMS rule to non-Medicare patients?

>

> It seems ethical to apply the rule for both patients, but my

partner wants to " push the envelope " and not apply the one on one rule

to the non-Medicare patients for the sake of the bottom line. Thus I

would be coding my units as if I was seeing both patients on an

individual basis. Am I being unintentionally fraudulent with the

non-Medicare contractors?

>

> Thanks in advance,

> Hankins, PT/President

> Synergy Therapies, LLC

>

>

>

>

[Guest guest]

Just show your partner the CPT codebook. Therapeutic

procedures requires " one on one " services by the

therapist. I however do not agree that therapeutic

exercise should be a " one on one " required service

like therapeutic activity, and feel it should be

redefined. If I see two ACL's simultaneously at 10:00

to 11:00, or one at 10:00 and one at 11:00 will I have

any difference in outcomes? Absolutely not. We can

multitask within reason. The PT's who abuse it and

have 3-4 patients at once are the ones whom

demonstrate poor ethics.

Bisesi MPT COMT

Winter Haven, Fl.

--- scott hankins wrote:

> Group,

>

> I know this has been discussed in the past, but it

> has become a matter of discussion between my partner

> and I. My partner is not a PT and looks at numbers

> only, not numbers and patient care like me.

>

> Here is the issue- During doubled up treatment

> slots when we are treating under the " one on one "

> rule from CMS, meaning the individual times equal

> the total treatment time for both patients, is it

> mandatory to apply this same CMS rule to

> non-Medicare patients?

>

> It seems ethical to apply the rule for both

> patients, but my partner wants to " push the

> envelope " and not apply the one on one rule to the

> non-Medicare patients for the sake of the bottom

> line. Thus I would be coding my units as if I was

> seeing both patients on an individual basis. Am I

> being unintentionally fraudulent with the

> non-Medicare contractors?

>

> Thanks in advance,

> Hankins, PT/President

> Synergy Therapies, LLC

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

________________________________________________________________________________\

____

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know-it-all with Yahoo! Mobile. Try it now.

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[Guest guest]

In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

mschwall@... writes:

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark

Interesting observation. I think it is easy to see publicly traded Physical

Therapy company's with unscrupulous NON PT's as the head creating problems.

It is easy to think that PT's are not involved in the problem. But as Lee

Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I worked in a

couple of privately held and one publicly traded PT Company. As this

company's Director of Internal Audit, I can tell you that I performed fraud

investigations on PT's that we incorrectly coding services and stealing from my

employer. As a CPA, I have read about some of the largest fraud cases being

perpetrated or assisted by CPA's. CPA Firms used to limit ownership to

strictly

CPA's for some of the reasons you are alluding to in your post. My point is

that it doesn't matter whether you are a PT, a respiratory therapist (of a

publicly traded company), a CPA or a stay at home caretaker. If you are

willing

to cheat/beat the system, you will. If you are interested in working an

honest days work for an honest days wage-you do. It doesn't matter what

position/status you carry in life, your character is what counts. Just because

you

are a PT or a CPA doesn't mean you have character, that comes from within.

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

**************It's Tax Time! Get tips, forms and advice on AOL Money &

Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850)

[Guest guest]

Jim:

Great comment.

While respecting you fully Mark, I don't believe the issue is as cut and dried

as you and some others might think. Let's put medicare completely to the side

on this since it has been aptly pointed out that the definitions of the CPT

codes are not Medicare's. There are few other payors in my experience (and I

acknowledge that this is different in different markets) that explicitly state

who are qualified providers. With medicare, they are very explicit-has to be a

PT or a PTA (the inconsistency on the PTA in regards to setting is crazy but

that is a different matter altogether).

In fact, most defer to state practice acts which although different, allow

delegation of some tasks to extenders under supervision. This implies that the

services are rendered by the PT. In the case of overlapping patients and the

use of extenders for some patients (e.g. therapeutic exercise one on one) isn't

practically violated as long as the supervision and state practice act is being

upheld.

This isn't any different than the surgical codes, office visits, or for that

matter the injection codes for a physician who obviously delegates components to

an extender (easy example is the office visit where blood pressure is done by

nurse). The MD codes the evaluation and is responsible for it but to believe

they did every portion literally themselves is ridiculous.

My point is not to argue whether exclusive one on one by a PT is the best or

preferred practice model but to point out that the interpretation of the code is

not as explicit as a faction of the PT's in our profession believe (and are

taught by many). I can honestly see where the quite literal translation of that

CPT code can be done and I believe that for the purposes of clarification that

it should be edited (specifically things like ther ex might be better served

with a modifier in supervised cases-just a thought realizing that it has all

kinds of implications). In fact, I think that our codes and the whole time vs.

service base while serving us well with its transition in the mid 90's is now a

thing of the past and should be scrapped for PT services and replaced with

office visits. Lastly on this point, my experience in viewing practice patterns

in for profit, non profit, public, and other outpatient clinics supports the

notion that PT's do in fact delegate tasks (again non federally funded patients)

and uphold their practice act. Yes, there are abusers of it and when they abuse

in my experience is that they aren't following the supervision guidelines which

are typically explicit in practice acts. Some might argue that just because the

prevailing mainstream practices, delegate tasks doesn't make it right or uphold

the CPT code definition (which they quite parochially interpret). On this point

I also disagree as I have seen much in case law (I am not an attorney and don't

play one on TV) based upon prevailing practice. How many on this list serve can

honestly state that 100% of all tasks that are billed are 100% of the time

rendered by a PT or a PTA?

The other aspect of this that I find appalling is that the whole transition to

autonomous practitioner flies in the face of the notion that a PT cannot

delegate. The only thing that rightfully matters is that the patient is under

care of a PT and that outcome is of the prime factor. Time based codes imply

that more is better (at least from a payment standpoint) when we know that many

of the most efficacious interventions don't hold that tenant.

Please also understand that my point is also not to debate this whole thing in

terms of " I am right you are wrong " but to at least point out that the

interpretation is not as one way as many point out and the prevailing practice

patterns do in fact have overlapping patients which are often times handled

appropriately with supervision of a PT.

__________________________________________

Larry

Larry Benz

PT Development LLC

13000 Equity Place Suite 105

Louisville, KY 40223

larry@... (best way to reach)

mobile (Spinvox converts voice to email)

office

(Fax: only if you must)

LarryBenz MyPhysicalTherapySpace.com ID

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________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

JHall49629@...

Sent: Tuesday, April 15, 2008 10:06 PM

To: PTManager

Subject: Re: One- on- One Treatment for Medicare vs. Non-Medicare

patients

In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

mschwall@... <mailto:mschwall%40comcast.net> writes:

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark

Interesting observation. I think it is easy to see publicly traded Physical

Therapy company's with unscrupulous NON PT's as the head creating problems.

It is easy to think that PT's are not involved in the problem. But as Lee

Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I worked in a

couple of privately held and one publicly traded PT Company. As this

company's Director of Internal Audit, I can tell you that I performed fraud

investigations on PT's that we incorrectly coding services and stealing from my

employer. As a CPA, I have read about some of the largest fraud cases being

perpetrated or assisted by CPA's. CPA Firms used to limit ownership to strictly

CPA's for some of the reasons you are alluding to in your post. My point is

that it doesn't matter whether you are a PT, a respiratory therapist (of a

publicly traded company), a CPA or a stay at home caretaker. If you are willing

to cheat/beat the system, you will. If you are interested in working an

honest days work for an honest days wage-you do. It doesn't matter what

position/status you carry in life, your character is what counts. Just because

you

are a PT or a CPA doesn't mean you have character, that comes from within.

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

**************It's Tax Time! Get tips, forms and advice on AOL Money &

Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850

<http://money.aol.com/tax?NCID=aolcmp00300000002850> )

[Guest guest]

Jim Hall wrote:

" My point is that it doesn't matter whether you are a PT, a respiratory

therapist (of a publicly traded company), a CPA or a stay at home caretaker.

If you are willing to cheat/beat the system, you will. If you are

interested in working an honest days work for an honest days wage-you do.

It doesn't matter what position/status you carry in life, your character is

what counts. Just because you are a PT or a CPA doesn't mean you have

character, that comes from within. "

HooAah, Jim!

I agree. Character's hard to fake.

Also, it's not " Simply Doing Business " to lie, cheat, and steal to acquire

more money. That's " theft " and ultimately, it's not profitable at all.

Further, it makes the rest of us look sleazy by association.

Regards to all,

Dr. Dick Hillyer,PT

Dr. W. Hillyer,PT,DPT,MBA,MSM

Hillyer Consulting

700 El Dorado Pkwy W.

Cape Coral, FL 33914

Home

Office

Mobile

_____

From: PTManager [mailto:PTManager ] On Behalf

Of JHall49629@...

Sent: Tuesday, April 15, 2008 10:06 PM

To: PTManager

Subject: Re: One- on- One Treatment for Medicare vs.

Non-Medicare patients

In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

mschwallcomcast (DOT) <mailto:mschwall%40comcast.net> net writes:

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark

Interesting observation. I think it is easy to see publicly traded Physical

Therapy company's with unscrupulous NON PT's as the head creating problems.

It is easy to think that PT's are not involved in the problem. But as Lee

Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I worked in a

couple of privately held and one publicly traded PT Company. As this

company's Director of Internal Audit, I can tell you that I performed fraud

investigations on PT's that we incorrectly coding services and stealing from

my

employer. As a CPA, I have read about some of the largest fraud cases being

perpetrated or assisted by CPA's. CPA Firms used to limit ownership to

strictly

CPA's for some of the reasons you are alluding to in your post. My point is

that it doesn't matter whether you are a PT, a respiratory therapist (of a

publicly traded company), a CPA or a stay at home caretaker. If you are

willing

to cheat/beat the system, you will. If you are interested in working an

honest days work for an honest days wage-you do. It doesn't matter what

position/status you carry in life, your character is what counts. Just

because you

are a PT or a CPA doesn't mean you have character, that comes from within.

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

**************It's Tax Time! Get tips, forms and advice on AOL Money &

Finance. (http://money. <http://money.aol.com/tax?NCID=aolcmp00300000002850>

aol.com/tax?NCID=aolcmp00300000002850)

[Guest guest]

Hi Larry,

In regards to your thoughts later in your post.

At my clinic (2 PT’s) that has been in business for 9 years, we have never

used a PTA or and aide for any part of treatment. Our aide functions

exclusively for set up and break down after treatment (in addition to other

clinic tasks). We do this even though our state practice act allows aides

to do “treatment tasks”. So yes, 100% of our billing for 9 years has been

done by a PT. (Please note we have nothing against PTA’s doing treatment

they are licensed to do)

We feel strongly that patients are coming to our clinic to see a PT, not a

care extender. The contract we sign with insurances are between us as PT’s

and the insurance and they are expecting their beneficiaries to be seen by a

PT. Now, I know many will argue this point in the sake of having a

profitable clinic, which is fine. I think the debate must continue. Our

clinic choice is a personal choice, but one which we feel is in the best

interests of our clients. They come to our clinic to see us, not an aide

and our standing in the community is growing because of that commitment.

This commitment makes billing a lot less complicated to do as well because

we bill for the time and procedures we do.

I also cringed after seeing other posts that seem to blow off the need and

input of a PT, such as saying that therapeutic exercise doesn’t really need

the one-on one intervention of a PT. It diminishes our profession. Why do

you think patients are given exercise sheet or told to see a personal

trainer for exercise instead of a PT? In part because we diminish our own

need instead of promoting our expertise.

Just my opinion for today.

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of Larry Benz

Sent: Wednesday, April 16, 2008 5:53 AM

To: PTManager

Subject: RE: One- on- One Treatment for Medicare vs.

Non-Medicare patients

Jim:

Great comment.

While respecting you fully Mark, I don't believe the issue is as cut and

dried as you and some others might think. Let's put medicare completely to

the side on this since it has been aptly pointed out that the definitions of

the CPT codes are not Medicare's. There are few other payors in my

experience (and I acknowledge that this is different in different markets)

that explicitly state who are qualified providers. With medicare, they are

very explicit-has to be a PT or a PTA (the inconsistency on the PTA in

regards to setting is crazy but that is a different matter altogether).

In fact, most defer to state practice acts which although different, allow

delegation of some tasks to extenders under supervision. This implies that

the services are rendered by the PT. In the case of overlapping patients and

the use of extenders for some patients (e.g. therapeutic exercise one on

one) isn't practically violated as long as the supervision and state

practice act is being upheld.

This isn't any different than the surgical codes, office visits, or for that

matter the injection codes for a physician who obviously delegates

components to an extender (easy example is the office visit where blood

pressure is done by nurse). The MD codes the evaluation and is responsible

for it but to believe they did every portion literally themselves is

ridiculous.

My point is not to argue whether exclusive one on one by a PT is the best or

preferred practice model but to point out that the interpretation of the

code is not as explicit as a faction of the PT's in our profession believe

(and are taught by many). I can honestly see where the quite literal

translation of that CPT code can be done and I believe that for the purposes

of clarification that it should be edited (specifically things like ther ex

might be better served with a modifier in supervised cases-just a thought

realizing that it has all kinds of implications). In fact, I think that our

codes and the whole time vs. service base while serving us well with its

transition in the mid 90's is now a thing of the past and should be scrapped

for PT services and replaced with office visits. Lastly on this point, my

experience in viewing practice patterns in for profit, non profit, public,

and other outpatient clinics supports the notion that PT's do in fact

delegate tasks (again non federally funded patients) and uphold their

practice act. Yes, there are abusers of it and when they abuse in my

experience is that they aren't following the supervision guidelines which

are typically explicit in practice acts. Some might argue that just because

the prevailing mainstream practices, delegate tasks doesn't make it right or

uphold the CPT code definition (which they quite parochially interpret). On

this point I also disagree as I have seen much in case law (I am not an

attorney and don't play one on TV) based upon prevailing practice. How many

on this list serve can honestly state that 100% of all tasks that are billed

are 100% of the time rendered by a PT or a PTA?

The other aspect of this that I find appalling is that the whole transition

to autonomous practitioner flies in the face of the notion that a PT cannot

delegate. The only thing that rightfully matters is that the patient is

under care of a PT and that outcome is of the prime factor. Time based codes

imply that more is better (at least from a payment standpoint) when we know

that many of the most efficacious interventions don't hold that tenant.

Please also understand that my point is also not to debate this whole thing

in terms of " I am right you are wrong " but to at least point out that the

interpretation is not as one way as many point out and the prevailing

practice patterns do in fact have overlapping patients which are often times

handled appropriately with supervision of a PT.

__________________________________________

Larry

Larry Benz

PT Development LLC

13000 Equity Place Suite 105

Louisville, KY 40223

larry@physicalthera <mailto:larry%40physicaltherapist.com> pist.com (best

way to reach)

mobile (Spinvox converts voice to email)

office

(Fax: only if you must)

LarryBenz MyPhysicalTherapySpace.com ID

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________________________________

From: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

[mailto:PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com] On

Behalf Of JHall49629aol (DOT) <mailto:JHall49629%40aol.com> com

Sent: Tuesday, April 15, 2008 10:06 PM

To: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

Subject: Re: One- on- One Treatment for Medicare vs.

Non-Medicare patients

In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

mschwallcomcast (DOT) <mailto:mschwall%40comcast.net> net

<mailto:mschwall%40comcast.net> writes:

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark

Interesting observation. I think it is easy to see publicly traded Physical

Therapy company's with unscrupulous NON PT's as the head creating problems.

It is easy to think that PT's are not involved in the problem. But as Lee

Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I worked in a

couple of privately held and one publicly traded PT Company. As this

company's Director of Internal Audit, I can tell you that I performed fraud

investigations on PT's that we incorrectly coding services and stealing from

my

employer. As a CPA, I have read about some of the largest fraud cases being

perpetrated or assisted by CPA's. CPA Firms used to limit ownership to

strictly

CPA's for some of the reasons you are alluding to in your post. My point is

that it doesn't matter whether you are a PT, a respiratory therapist (of a

publicly traded company), a CPA or a stay at home caretaker. If you are

willing

to cheat/beat the system, you will. If you are interested in working an

honest days work for an honest days wage-you do. It doesn't matter what

position/status you carry in life, your character is what counts. Just

because you

are a PT or a CPA doesn't mean you have character, that comes from within.

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

**************It's Tax Time! Get tips, forms and advice on AOL Money &

Finance. (http://money. <http://money.aol.com/tax?NCID=aolcmp00300000002850>

aol.com/tax?NCID=aolcmp00300000002850 <http://money.

<http://money.aol.com/tax?NCID=aolcmp00300000002850>

aol.com/tax?NCID=aolcmp00300000002850> )

[Guest guest]

Hi Everyone,

Just a quick reminder that Helene Fearon, PT sits on the CPT Editorial Panel

and has been a member for a number of years.

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of Milano, Dave

Sent: Wednesday, April 16, 2008 7:36 AM

To: PTManager

Subject: RE: One- on- One Treatment for Medicare vs.

Non-Medicare patients

Regarding this:

" ...it has been aptly pointed out that the definitions of the CPT codes are

not Medicare's. "

In some very important ways, this is very much NOT true. CPT codes are

" officially " owned by the AMA, but they are managed by a panel that includes

all the major players in today's medical care machine. These folks control

the massive system of medical care financing very neatly and tightly.

Government, mega-insurance, and the AMA are allied into a single force here.

Please read carefully this quote from the Professional Resources section of

the AMA website page regarding CPT codes:

" The CPT Editorial Panel is responsible for maintaining the CPT code set.

This panel is authorized to revise, update, or modify the CPT codes. The

Panel is comprised of 17 members. Of these, 11 are physicians nominated by

the National Medical Specialty Societies and approved by the AMA Board of

Trustees; one physician each nominated from the Blue Cross and Blue Shield

Association, the America's Health Insurance Plans, the American Hospital

Association, and the Centers for Medicare and Medicaid Services (CMS); one

Performance Measures representative (formerly a managed care seat) is chosen

from nominees solicited from Performance Measures development organizations

and appointed by the AMA Board of Trustees, and two members of the CPT

Health Care Professionals Advisory Committee (co-chair and one member at

large). "

It's very nice of the AMA to be so helpful to insurance companies and

government in establishing the CPT system. It is, I'm sure, mere coincidence

that this triumvirate now speaks with a single voice in determining,

defining, and dictating what healthcare is.

Dave Milano, PT, Director of Rehab Services

Laurel Health System

Re: One- on- One Treatment for Medicare vs.

Non-Medicare patients

In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

mschwallcomcast (DOT) ­net<mailto:mschwall%40comcast.net>

<mailto:mschwall%­40comcast.­net> writes:

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark

Interesting observation. I think it is easy to see publicly traded Physical

Therapy company's with unscrupulous NON PT's as the head creating problems.

It is easy to think that PT's are not involved in the problem. But as Lee

Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I worked in a

couple of privately held and one publicly traded PT Company. As this

company's Director of Internal Audit, I can tell you that I performed fraud

investigations on PT's that we incorrectly coding services and stealing from

my

employer. As a CPA, I have read about some of the largest fraud cases being

perpetrated or assisted by CPA's. CPA Firms used to limit ownership to

strictly

CPA's for some of the reasons you are alluding to in your post. My point is

that it doesn't matter whether you are a PT, a respiratory therapist (of a

publicly traded company), a CPA or a stay at home caretaker. If you are

willing

to cheat/beat the system, you will. If you are interested in working an

honest days work for an honest days wage-you do. It doesn't matter what

position/status you carry in life, your character is what counts. Just

because you

are a PT or a CPA doesn't mean you have character, that comes from within.

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

************­**It's Tax Time! Get tips, forms and advice on AOL Money &

Finance. (

http://money.­aol.com/tax?­NCID=aolcmp00300­000002850<http://money.

<http://money.aol.com/tax?NCID=aolcmp00300000002850>

aol.com/tax?NCID=aolcmp00300000002850> <

http://money.­aol.com/tax?­NCID=aolcmp00300­000002850<http://money.

<http://money.aol.com/tax?NCID=aolcmp00300000002850>

aol.com/tax?NCID=aolcmp00300000002850>> )

[Guest guest]

Jim,

I agree with you that licensure does not ensure that one is of sound

character or incapable of unscrupulous behavior. My point however was in

regards to accountability. An unlicensed owner has no accountability to the

profession and is not within the reach of regulatory agencies which lends

itself to a certain mentality of " freedom " from regulatory . Your example

of the " Publicly traded companies " is a prime illustration of my point.

While the past misconduct of a certain very large publicly traded company is

unquestionable, it seems strange to me that not a single licensee was held

to account on behalf of the consumers for the well publicized illicit

billing practices despite the fact that each licensee is supposed to be

accountable for the billing for their services? And if this had indeed

happened I'm certain that the defense would have been that they only did as

they were directed by superiors and weren't aware that they were violating

the law. In this scenario I most certainly would have been sympathetic but

we all know that ignorance of the law is an inadequate defense. I also

recognize that some may ask how this would apply to the institutional

setting. Just as a point of clarification institutional settings are

licensed and therefore accountable. I'm not stating that the current model

of CPT coding or billing policies of third party payers or that certain

regulatory restrictions are reasonable but this doesn't excuse ignoring

them.

In my view this issue is about control and accountability and you can't

control what you don't own and it is difficult to be accountable for what

you don't control. Attorneys understand this, physicians understand this,

and most other professions understand this. Without ownership and control,

we as providers and our services amount to nothing more than a commodity

which some might argue has already or is happening. I would argue, only if

by our own inaction we allow it.

Always enjoy the back and forth.

Mark F. Schwall, PT

Future Physical Therapy, PC

1594 Route 9

Unit 2

Toms River, NJ 08755

Fax

Skype mfschwall

President

New Jersey Society of Independent Physical Therapists

2123 Route 35

Sea Girt, NJ 08750

From: PTManager [mailto:PTManager ] On Behalf

Of JHall49629@...

Sent: Tuesday, April 15, 2008 10:06 PM

To: PTManager

Subject: Re: One- on- One Treatment for Medicare vs.

Non-Medicare patients

In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

mschwall@... <mailto:mschwall%40comcast.net> writes:

Also as an observation and purely editorial comment I always find it

interesting that those who have no particular accountability due to being a

non-licensed " owner " always seem to be the most willing to " push the

envelope " with respect to billing and reimbursement behaviors. Do we need

any more evidence that ownership of Physical Therapy services should be

strictly limited to only licensed Physical Therapists? How long are we, as

licensees, going to continue to be willing to be accountable for the conduct

of those who cannot be held accountable?

Mark

Interesting observation. I think it is easy to see publicly traded Physical

Therapy company's with unscrupulous NON PT's as the head creating problems.

It is easy to think that PT's are not involved in the problem. But as Lee

Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I worked in a

couple of privately held and one publicly traded PT Company. As this

company's Director of Internal Audit, I can tell you that I performed fraud

investigations on PT's that we incorrectly coding services and stealing from

my

employer. As a CPA, I have read about some of the largest fraud cases being

perpetrated or assisted by CPA's. CPA Firms used to limit ownership to

strictly

CPA's for some of the reasons you are alluding to in your post. My point is

that it doesn't matter whether you are a PT, a respiratory therapist (of a

publicly traded company), a CPA or a stay at home caretaker. If you are

willing

to cheat/beat the system, you will. If you are interested in working an

honest days work for an honest days wage-you do. It doesn't matter what

position/status you carry in life, your character is what counts. Just

because you

are a PT or a CPA doesn't mean you have character, that comes from within.

Jim Hall, CPA <///><

General Manager

Rehab Management Services, LLC

Cedar Rapids, IA

319/892-0142

**************It's Tax Time! Get tips, forms and advice on AOL Money &

Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850)

[Guest guest]

,

I am one of the posters who stated that therapeutic

exercise should not require one on one contact. I

probably should not have been so vague. I still

strongly feel that therapeutic exercise should not

have a one on one PT contact requirement. The ther ex

procedure should not be held to the same contact

requirements as a therapeutic activity or neuro re-ed

procedure that warrants our interaction 100% of the

billable treatment time. Activities falling under ther

ex are no where near as skilled a service as a

therapeutic activity or neuro re-ed activity. With

ther ex, the skill is in the exercise prescription,

the teaching of the mechanics, the assessment of

patient performance with correct mechanics, and the

patient response to the exercise set. Ther ex does not

require our skills for " 3 sets of 10. " Ther activity

and neuro re-ed usually warrant our constant

interaction. Ther ex should be able to be billed for

more than one person at a time, or we should only be

able to bill for the time during the exercise session

that requires our instruction and monitoring. Patients

do not need our constant monitoring after we

demonstrate a new exercise, then after perhaps 5 reps

demonstrate correct mechanics. The patient doesn't

need us again until they finish and we assess

response.

Bisesi MPT COMT

Winter Haven, FL

--- thomas m howell wrote:

> Hi Larry,

>

>

>

> In regards to your thoughts later in your post.

>

>

>

> At my clinic (2 PT’s) that has been in business for

> 9 years, we have never

> used a PTA or and aide for any part of treatment.

> Our aide functions

> exclusively for set up and break down after

> treatment (in addition to other

> clinic tasks). We do this even though our state

> practice act allows aides

> to do “treatment tasks”. So yes, 100% of our

> billing for 9 years has been

> done by a PT. (Please note we have nothing against

> PTA’s doing treatment

> they are licensed to do)

>

>

>

> We feel strongly that patients are coming to our

> clinic to see a PT, not a

> care extender. The contract we sign with insurances

> are between us as PT’s

> and the insurance and they are expecting their

> beneficiaries to be seen by a

> PT. Now, I know many will argue this point in the

> sake of having a

> profitable clinic, which is fine. I think the

> debate must continue. Our

> clinic choice is a personal choice, but one which we

> feel is in the best

> interests of our clients. They come to our clinic

> to see us, not an aide

> and our standing in the community is growing because

> of that commitment.

> This commitment makes billing a lot less complicated

> to do as well because

> we bill for the time and procedures we do.

>

>

>

> I also cringed after seeing other posts that seem to

> blow off the need and

> input of a PT, such as saying that therapeutic

> exercise doesn’t really need

> the one-on one intervention of a PT. It diminishes

> our profession. Why do

> you think patients are given exercise sheet or told

> to see a personal

> trainer for exercise instead of a PT? In part

> because we diminish our own

> need instead of promoting our expertise.

>

>

>

> Just my opinion for today.

>

>

>

> Tom Howell, P.T., M.P.T.

>

> Howell Physical Therapy

>

> Eagle, ID

>

> howellpt@...

>

>

>

> _____

>

> From: PTManager

> [mailto:PTManager ] On Behalf

> Of Larry Benz

> Sent: Wednesday, April 16, 2008 5:53 AM

> To: PTManager

> Subject: RE: One- on- One Treatment for

> Medicare vs.

> Non-Medicare patients

>

>

>

> Jim:

>

> Great comment.

>

> While respecting you fully Mark, I don't believe the

> issue is as cut and

> dried as you and some others might think. Let's put

> medicare completely to

> the side on this since it has been aptly pointed out

> that the definitions of

> the CPT codes are not Medicare's. There are few

> other payors in my

> experience (and I acknowledge that this is different

> in different markets)

> that explicitly state who are qualified providers.

> With medicare, they are

> very explicit-has to be a PT or a PTA (the

> inconsistency on the PTA in

> regards to setting is crazy but that is a different

> matter altogether).

>

> In fact, most defer to state practice acts which

> although different, allow

> delegation of some tasks to extenders under

> supervision. This implies that

> the services are rendered by the PT. In the case of

> overlapping patients and

> the use of extenders for some patients (e.g.

> therapeutic exercise one on

> one) isn't practically violated as long as the

> supervision and state

> practice act is being upheld.

>

> This isn't any different than the surgical codes,

> office visits, or for that

> matter the injection codes for a physician who

> obviously delegates

> components to an extender (easy example is the

> office visit where blood

> pressure is done by nurse). The MD codes the

> evaluation and is responsible

> for it but to believe they did every portion

> literally themselves is

> ridiculous.

>

> My point is not to argue whether exclusive one on

> one by a PT is the best or

> preferred practice model but to point out that the

> interpretation of the

> code is not as explicit as a faction of the PT's in

> our profession believe

> (and are taught by many). I can honestly see where

> the quite literal

> translation of that CPT code can be done and I

> believe that for the purposes

> of clarification that it should be edited

> (specifically things like ther ex

> might be better served with a modifier in supervised

> cases-just a thought

> realizing that it has all kinds of implications). In

> fact, I think that our

> codes and the whole time vs. service base while

> serving us well with its

> transition in the mid 90's is now a thing of the

> past and should be scrapped

> for PT services and replaced with office visits.

> Lastly on this point, my

> experience in viewing practice patterns in for

> profit, non profit, public,

> and other outpatient clinics supports the notion

> that PT's do in fact

> delegate tasks (again non federally funded patients)

> and uphold their

> practice act. Yes, there are abusers of it and when

> they abuse in my

> experience is that they aren't following the

> supervision guidelines which

> are typically explicit in practice acts. Some might

> argue that just because

> the prevailing mainstream practices, delegate tasks

> doesn't make it right or

> uphold the CPT code definition (which they quite

> parochially interpret). On

> this point I also disagree as I have seen much in

> case law (I am not an

> attorney and don't play one on TV) based upon

> prevailing practice. How many

> on this list serve can honestly state that 100% of

> all tasks that are billed

> are 100% of the time rendered by a PT or a PTA?

>

> The other aspect of this that I find appalling is

> that the whole transition

> to autonomous practitioner flies in the face of the

> notion that a PT cannot

> delegate. The only thing that rightfully matters is

> that the patient is

> under care of a PT and that outcome is of the prime

> factor. Time based codes

> imply that more is better (at least from a payment

> standpoint) when we know

> that many of the most efficacious interventions

> don't hold that tenant.

>

> Please also understand that my point is also not to

> debate this whole thing

> in terms of " I am right you are wrong " but to at

> least point out that the

> interpretation is not as one way as many point out

> and the prevailing

> practice patterns do in fact have overlapping

> patients which are often times

> handled appropriately with supervision of a PT.

>

>

=== message truncated ===

________________________________________________________________________________\

____

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know-it-all with Yahoo! Mobile. Try it now.

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[Guest guest]

,

Doesn't that depend on what kind of ther. ex. you're talking about. Example:

Using a PNF techniques like slow reversal, hold, relax would be one on one.

Jim Arceneaux, LOTR

keith bisesi wrote:

,

I am one of the posters who stated that therapeutic

exercise should not require one on one contact. I

probably should not have been so vague. I still

strongly feel that therapeutic exercise should not

have a one on one PT contact requirement. The ther ex

procedure should not be held to the same contact

requirements as a therapeutic activity or neuro re-ed

procedure that warrants our interaction 100% of the

billable treatment time. Activities falling under ther

ex are no where near as skilled a service as a

therapeutic activity or neuro re-ed activity. With

ther ex, the skill is in the exercise prescription,

the teaching of the mechanics, the assessment of

patient performance with correct mechanics, and the

patient response to the exercise set. Ther ex does not

require our skills for " 3 sets of 10. " Ther activity

and neuro re-ed usually warrant our constant

interaction. Ther ex should be able to be billed for

more than one person at a time, or we should only be

able to bill for the time during the exercise session

that requires our instruction and monitoring. Patients

do not need our constant monitoring after we

demonstrate a new exercise, then after perhaps 5 reps

demonstrate correct mechanics. The patient doesn't

need us again until they finish and we assess

response.

Bisesi MPT COMT

Winter Haven, FL

--- thomas m howell wrote:

> Hi Larry,

>

>

>

> In regards to your thoughts later in your post.

>

>

>

> At my clinic (2 PT’s) that has been in business for

> 9 years, we have never

> used a PTA or and aide for any part of treatment.

> Our aide functions

> exclusively for set up and break down after

> treatment (in addition to other

> clinic tasks). We do this even though our state

> practice act allows aides

> to do “treatment tasks”. So yes, 100% of our

> billing for 9 years has been

> done by a PT. (Please note we have nothing against

> PTA’s doing treatment

> they are licensed to do)

>

>

>

> We feel strongly that patients are coming to our

> clinic to see a PT, not a

> care extender. The contract we sign with insurances

> are between us as PT’s

> and the insurance and they are expecting their

> beneficiaries to be seen by a

> PT. Now, I know many will argue this point in the

> sake of having a

> profitable clinic, which is fine. I think the

> debate must continue. Our

> clinic choice is a personal choice, but one which we

> feel is in the best

> interests of our clients. They come to our clinic

> to see us, not an aide

> and our standing in the community is growing because

> of that commitment.

> This commitment makes billing a lot less complicated

> to do as well because

> we bill for the time and procedures we do.

>

>

>

> I also cringed after seeing other posts that seem to

> blow off the need and

> input of a PT, such as saying that therapeutic

> exercise doesn’t really need

> the one-on one intervention of a PT. It diminishes

> our profession. Why do

> you think patients are given exercise sheet or told

> to see a personal

> trainer for exercise instead of a PT? In part

> because we diminish our own

> need instead of promoting our expertise.

>

>

>

> Just my opinion for today.

>

>

>

> Tom Howell, P.T., M.P.T.

>

> Howell Physical Therapy

>

> Eagle, ID

>

> howellpt@...

>

>

>

> _____

>

> From: PTManager

> [mailto:PTManager ] On Behalf

> Of Larry Benz

> Sent: Wednesday, April 16, 2008 5:53 AM

> To: PTManager

> Subject: RE: One- on- One Treatment for

> Medicare vs.

> Non-Medicare patients

>

>

>

> Jim:

>

> Great comment.

>

> While respecting you fully Mark, I don't believe the

> issue is as cut and

> dried as you and some others might think. Let's put

> medicare completely to

> the side on this since it has been aptly pointed out

> that the definitions of

> the CPT codes are not Medicare's. There are few

> other payors in my

> experience (and I acknowledge that this is different

> in different markets)

> that explicitly state who are qualified providers.

> With medicare, they are

> very explicit-has to be a PT or a PTA (the

> inconsistency on the PTA in

> regards to setting is crazy but that is a different

> matter altogether).

>

> In fact, most defer to state practice acts which

> although different, allow

> delegation of some tasks to extenders under

> supervision. This implies that

> the services are rendered by the PT. In the case of

> overlapping patients and

> the use of extenders for some patients (e.g.

> therapeutic exercise one on

> one) isn't practically violated as long as the

> supervision and state

> practice act is being upheld.

>

> This isn't any different than the surgical codes,

> office visits, or for that

> matter the injection codes for a physician who

> obviously delegates

> components to an extender (easy example is the

> office visit where blood

> pressure is done by nurse). The MD codes the

> evaluation and is responsible

> for it but to believe they did every portion

> literally themselves is

> ridiculous.

>

> My point is not to argue whether exclusive one on

> one by a PT is the best or

> preferred practice model but to point out that the

> interpretation of the

> code is not as explicit as a faction of the PT's in

> our profession believe

> (and are taught by many). I can honestly see where

> the quite literal

> translation of that CPT code can be done and I

> believe that for the purposes

> of clarification that it should be edited

> (specifically things like ther ex

> might be better served with a modifier in supervised

> cases-just a thought

> realizing that it has all kinds of implications). In

> fact, I think that our

> codes and the whole time vs. service base while

> serving us well with its

> transition in the mid 90's is now a thing of the

> past and should be scrapped

> for PT services and replaced with office visits.

> Lastly on this point, my

> experience in viewing practice patterns in for

> profit, non profit, public,

> and other outpatient clinics supports the notion

> that PT's do in fact

> delegate tasks (again non federally funded patients)

> and uphold their

> practice act. Yes, there are abusers of it and when

> they abuse in my

> experience is that they aren't following the

> supervision guidelines which

> are typically explicit in practice acts. Some might

> argue that just because

> the prevailing mainstream practices, delegate tasks

> doesn't make it right or

> uphold the CPT code definition (which they quite

> parochially interpret). On

> this point I also disagree as I have seen much in

> case law (I am not an

> attorney and don't play one on TV) based upon

> prevailing practice. How many

> on this list serve can honestly state that 100% of

> all tasks that are billed

> are 100% of the time rendered by a PT or a PTA?

>

> The other aspect of this that I find appalling is

> that the whole transition

> to autonomous practitioner flies in the face of the

> notion that a PT cannot

> delegate. The only thing that rightfully matters is

> that the patient is

> under care of a PT and that outcome is of the prime

> factor. Time based codes

> imply that more is better (at least from a payment

> standpoint) when we know

> that many of the most efficacious interventions

> don't hold that tenant.

>

> Please also understand that my point is also not to

> debate this whole thing

> in terms of " I am right you are wrong " but to at

> least point out that the

> interpretation is not as one way as many point out

> and the prevailing

> practice patterns do in fact have overlapping

> patients which are often times

> handled appropriately with supervision of a PT.

>

>

=== message truncated ===

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[Guest guest]

Hi ,

Whether you believe it or not, your post proved my point, that therapeutic

exercise, as indicated by the CPT code for therapeutic exercise, is a

one-on-one activity. And you're correct in acknowledging that only our

one-on-one time spent in " exercise prescription, the teaching of the

mechanics, the assessment of patient performance with correct mechanics, and

the patient response to the exercise set (from your post) " is what we are

supposed to be billing for. Anything else is not covered by the CPT code.

I still respectfully disagree that patients " don't need us. " (from your

post). Which patients? Many do need constant attention due to complicating

factors, additional diagnoses, age etc. Your statements may hold up to high

level patients but not to all. Even high level uncomplicated patients need

coaching and encouragement which, though not a " skilled service " by the

book, is something therapists tend to overlook in its importance. This is a

one-on-one activity we have really lost to personal trainers who have

created a profitable business out of our diminishing our own skill and

expertise.

Assessing patients that need additional one-on-one intervention when doing

exercise sets, having a strong philosophy of coaching and encouraging them

and following the skilled services that are listed above and are the basis

for the CPT code.These are the hallmarks of our philosophy and belief that

therapeutic exercise IS a one-on-one activity.

I also acknowledge that the CPT codes for therapeutic exercise as well as

neuromuscular training do not adequately capture the realities of practice

in the real world. The fundamental question that you are really asking is

" Should we be paid for the aide staff time to supervise, equipment use (wear

and tear) and periodic PT supervision of clients without complicating

factors, that are advanced enough to do a supervised independent or

unsupervised independent exercise program in our clinic? " Right now we

cannot directly bill for this, by strict interpretation of the CPT codes.

These factors are folded into the formula for setting fee schedules.

Occasionally, we still have patients that do exercise sets and independent

skills. If they are doing this, we are not billing for it unless there is

some skilled intervention involved as well. I can say that this is a rare

thing in our clinic as most are discharged by the time they reach this level

or are doing their exercises at home or at the gym and coming to see us for

the remaining parts of their treatment.

These leads me back to giving suggestions on improving the CPT coding

system. Instead of debating this point further, how would you suggest the

coding for therapeutic exercise (actually all of the exercise-based codes)

be modified and expanded to capture the realities of practice today? I look

forward to your comments

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of keith bisesi

Sent: Thursday, April 17, 2008 11:31 AM

To: PTManager

Subject: RE: One- on- One Treatment for Medicare vs.

Non-Medicare patients

,

I am one of the posters who stated that therapeutic

exercise should not require one on one contact. I

probably should not have been so vague. I still

strongly feel that therapeutic exercise should not

have a one on one PT contact requirement. The ther ex

procedure should not be held to the same contact

requirements as a therapeutic activity or neuro re-ed

procedure that warrants our interaction 100% of the

billable treatment time. Activities falling under ther

ex are no where near as skilled a service as a

therapeutic activity or neuro re-ed activity. With

ther ex, the skill is in the exercise prescription,

the teaching of the mechanics, the assessment of

patient performance with correct mechanics, and the

patient response to the exercise set. Ther ex does not

require our skills for " 3 sets of 10. " Ther activity

and neuro re-ed usually warrant our constant

interaction. Ther ex should be able to be billed for

more than one person at a time, or we should only be

able to bill for the time during the exercise session

that requires our instruction and monitoring. Patients

do not need our constant monitoring after we

demonstrate a new exercise, then after perhaps 5 reps

demonstrate correct mechanics. The patient doesn't

need us again until they finish and we assess

response.

Bisesi MPT COMT

Winter Haven, FL

--- thomas m howell <thowellfiberpipe (DOT) <mailto:thowell%40fiberpipe.net>

net> wrote:

> Hi Larry,

>

>

>

> In regards to your thoughts later in your post.

>

>

>

> At my clinic (2 PT's) that has been in business for

> 9 years, we have never

> used a PTA or and aide for any part of treatment.

> Our aide functions

> exclusively for set up and break down after

> treatment (in addition to other

> clinic tasks). We do this even though our state

> practice act allows aides

> to do " treatment tasks " . So yes, 100% of our

> billing for 9 years has been

> done by a PT. (Please note we have nothing against

> PTA's doing treatment

> they are licensed to do)

>

>

>

> We feel strongly that patients are coming to our

> clinic to see a PT, not a

> care extender. The contract we sign with insurances

> are between us as PT's

> and the insurance and they are expecting their

> beneficiaries to be seen by a

> PT. Now, I know many will argue this point in the

> sake of having a

> profitable clinic, which is fine. I think the

> debate must continue. Our

> clinic choice is a personal choice, but one which we

> feel is in the best

> interests of our clients. They come to our clinic

> to see us, not an aide

> and our standing in the community is growing because

> of that commitment.

> This commitment makes billing a lot less complicated

> to do as well because

> we bill for the time and procedures we do.

>

>

>

> I also cringed after seeing other posts that seem to

> blow off the need and

> input of a PT, such as saying that therapeutic

> exercise doesn't really need

> the one-on one intervention of a PT. It diminishes

> our profession. Why do

> you think patients are given exercise sheet or told

> to see a personal

> trainer for exercise instead of a PT? In part

> because we diminish our own

> need instead of promoting our expertise.

>

>

>

> Just my opinion for today.

>

>

>

> Tom Howell, P.T., M.P.T.

>

> Howell Physical Therapy

>

> Eagle, ID

>

> howellptfiberpipe (DOT) <mailto:howellpt%40fiberpipe.net> net

>

>

>

> _____

>

> From: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

> [mailto:PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com]

On Behalf

> Of Larry Benz

> Sent: Wednesday, April 16, 2008 5:53 AM

> To: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

> Subject: RE: One- on- One Treatment for

> Medicare vs.

> Non-Medicare patients

>

>

>

> Jim:

>

> Great comment.

>

> While respecting you fully Mark, I don't believe the

> issue is as cut and

> dried as you and some others might think. Let's put

> medicare completely to

> the side on this since it has been aptly pointed out

> that the definitions of

> the CPT codes are not Medicare's. There are few

> other payors in my

> experience (and I acknowledge that this is different

> in different markets)

> that explicitly state who are qualified providers.

> With medicare, they are

> very explicit-has to be a PT or a PTA (the

> inconsistency on the PTA in

> regards to setting is crazy but that is a different

> matter altogether).

>

> In fact, most defer to state practice acts which

> although different, allow

> delegation of some tasks to extenders under

> supervision. This implies that

> the services are rendered by the PT. In the case of

> overlapping patients and

> the use of extenders for some patients (e.g.

> therapeutic exercise one on

> one) isn't practically violated as long as the

> supervision and state

> practice act is being upheld.

>

> This isn't any different than the surgical codes,

> office visits, or for that

> matter the injection codes for a physician who

> obviously delegates

> components to an extender (easy example is the

> office visit where blood

> pressure is done by nurse). The MD codes the

> evaluation and is responsible

> for it but to believe they did every portion

> literally themselves is

> ridiculous.

>

> My point is not to argue whether exclusive one on

> one by a PT is the best or

> preferred practice model but to point out that the

> interpretation of the

> code is not as explicit as a faction of the PT's in

> our profession believe

> (and are taught by many). I can honestly see where

> the quite literal

> translation of that CPT code can be done and I

> believe that for the purposes

> of clarification that it should be edited

> (specifically things like ther ex

> might be better served with a modifier in supervised

> cases-just a thought

> realizing that it has all kinds of implications). In

> fact, I think that our

> codes and the whole time vs. service base while

> serving us well with its

> transition in the mid 90's is now a thing of the

> past and should be scrapped

> for PT services and replaced with office visits.

> Lastly on this point, my

> experience in viewing practice patterns in for

> profit, non profit, public,

> and other outpatient clinics supports the notion

> that PT's do in fact

> delegate tasks (again non federally funded patients)

> and uphold their

> practice act. Yes, there are abusers of it and when

> they abuse in my

> experience is that they aren't following the

> supervision guidelines which

> are typically explicit in practice acts. Some might

> argue that just because

> the prevailing mainstream practices, delegate tasks

> doesn't make it right or

> uphold the CPT code definition (which they quite

> parochially interpret). On

> this point I also disagree as I have seen much in

> case law (I am not an

> attorney and don't play one on TV) based upon

> prevailing practice. How many

> on this list serve can honestly state that 100% of

> all tasks that are billed

> are 100% of the time rendered by a PT or a PTA?

>

> The other aspect of this that I find appalling is

> that the whole transition

> to autonomous practitioner flies in the face of the

> notion that a PT cannot

> delegate. The only thing that rightfully matters is

> that the patient is

> under care of a PT and that outcome is of the prime

> factor. Time based codes

> imply that more is better (at least from a payment

> standpoint) when we know

> that many of the most efficacious interventions

> don't hold that tenant.

>

> Please also understand that my point is also not to

> debate this whole thing

> in terms of " I am right you are wrong " but to at

> least point out that the

> interpretation is not as one way as many point out

> and the prevailing

> practice patterns do in fact have overlapping

> patients which are often times

> handled appropriately with supervision of a PT.

>

>

=== message truncated ===

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[Guest guest]

That's exactly my point. But involved activities like

those should be billed therapeutic activity or neuro

re-ed. Obviously a skilled technique, such as

manually applied PNF patterns or hold relax etc, even

just simple AAROM require more skill than teaching

someone bridging and counting 3 sets of 10 with them.

Why should these be held to the same

contact/interaction standards by the AMA's CPT coding?

Bisesi MPT COMT.

Winter Haven, FL

--- Jim wrote:

> ,

>

> Doesn't that depend on what kind of ther. ex.

> you're talking about. Example: Using a PNF

> techniques like slow reversal, hold, relax would be

> one on one.

> Jim Arceneaux, LOTR

>

> keith bisesi wrote:

> ,

>

> I am one of the posters who stated that therapeutic

> exercise should not require one on one contact. I

> probably should not have been so vague. I still

> strongly feel that therapeutic exercise should not

> have a one on one PT contact requirement. The ther

> ex

> procedure should not be held to the same contact

> requirements as a therapeutic activity or neuro

> re-ed

> procedure that warrants our interaction 100% of the

> billable treatment time. Activities falling under

> ther

> ex are no where near as skilled a service as a

> therapeutic activity or neuro re-ed activity. With

> ther ex, the skill is in the exercise prescription,

> the teaching of the mechanics, the assessment of

> patient performance with correct mechanics, and the

> patient response to the exercise set. Ther ex does

> not

> require our skills for " 3 sets of 10. " Ther activity

> and neuro re-ed usually warrant our constant

> interaction. Ther ex should be able to be billed for

> more than one person at a time, or we should only be

> able to bill for the time during the exercise

> session

> that requires our instruction and monitoring.

> Patients

> do not need our constant monitoring after we

> demonstrate a new exercise, then after perhaps 5

> reps

> demonstrate correct mechanics. The patient doesn't

> need us again until they finish and we assess

> response.

>

> Bisesi MPT COMT

> Winter Haven, FL

>

> --- thomas m howell wrote:

>

> > Hi Larry,

> >

> >

> >

> > In regards to your thoughts later in your post.

> >

> >

> >

> > At my clinic (2 PT’s) that has been in business

> for

> > 9 years, we have never

> > used a PTA or and aide for any part of treatment.

> > Our aide functions

> > exclusively for set up and break down after

> > treatment (in addition to other

> > clinic tasks). We do this even though our state

> > practice act allows aides

> > to do “treatment tasks”. So yes, 100% of our

> > billing for 9 years has been

> > done by a PT. (Please note we have nothing against

> > PTA’s doing treatment

> > they are licensed to do)

> >

> >

> >

> > We feel strongly that patients are coming to our

> > clinic to see a PT, not a

> > care extender. The contract we sign with

> insurances

> > are between us as PT’s

> > and the insurance and they are expecting their

> > beneficiaries to be seen by a

> > PT. Now, I know many will argue this point in the

> > sake of having a

> > profitable clinic, which is fine. I think the

> > debate must continue. Our

> > clinic choice is a personal choice, but one which

> we

> > feel is in the best

> > interests of our clients. They come to our clinic

> > to see us, not an aide

> > and our standing in the community is growing

> because

> > of that commitment.

> > This commitment makes billing a lot less

> complicated

> > to do as well because

> > we bill for the time and procedures we do.

> >

> >

> >

> > I also cringed after seeing other posts that seem

> to

> > blow off the need and

> > input of a PT, such as saying that therapeutic

> > exercise doesn’t really need

> > the one-on one intervention of a PT. It diminishes

> > our profession. Why do

> > you think patients are given exercise sheet or

> told

> > to see a personal

> > trainer for exercise instead of a PT? In part

> > because we diminish our own

> > need instead of promoting our expertise.

> >

> >

> >

> > Just my opinion for today.

> >

> >

> >

> > Tom Howell, P.T., M.P.T.

> >

> > Howell Physical Therapy

> >

> > Eagle, ID

> >

> > howellpt@...

> >

> >

> >

> > _____

> >

> > From: PTManager

> > [mailto:PTManager ] On Behalf

> > Of Larry Benz

> > Sent: Wednesday, April 16, 2008 5:53 AM

> > To: PTManager

> > Subject: RE: One- on- One Treatment

> for

> > Medicare vs.

> > Non-Medicare patients

> >

> >

> >

> > Jim:

> >

> > Great comment.

> >

> > While respecting you fully Mark, I don't believe

> the

> > issue is as cut and

> > dried as you and some others might think. Let's

> put

> > medicare completely to

> > the side on this since it has been aptly pointed

> out

> > that the definitions of

> > the CPT codes are not Medicare's. There are few

> > other payors in my

> > experience (and I acknowledge that this is

> different

> > in different markets)

> > that explicitly state who are qualified providers.

> > With medicare, they are

> > very explicit-has to be a PT or a PTA (the

> > inconsistency on the PTA in

> > regards to setting is crazy but that is a

> different

> > matter altogether).

> >

> > In fact, most defer to state practice acts which

> > although different, allow

> > delegation of some tasks to extenders under

> > supervision. This implies that

> > the services are rendered by the PT. In the case

> of

> > overlapping patients and

> > the use of extenders for some patients (e.g.

> > therapeutic exercise one on

> > one) isn't practically violated as long as the

> > supervision and state

> > practice act is being upheld.

> >

> > This isn't any different than the surgical codes,

> > office visits, or for that

> > matter the injection codes for a physician who

> > obviously delegates

> > components to an extender (easy example is the

> > office visit where blood

> > pressure is done by nurse). The MD codes the

> > evaluation and is responsible

> > for it but to believe they did every portion

> > literally themselves is

> > ridiculous.

> >

> > My point is not to argue whether exclusive one on

> > one by a PT is the best or

> > preferred practice model but to point out that the

> > interpretation of the

> > code is not as explicit as a faction of the PT's

> in

>

=== message truncated ===

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____

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[Guest guest]

Therapeutic exercise is a one-on-one direct contact

CPT code because it requires the skills of a

therapist, or an assistant under the supervision of a

therapist, to teach, educate, and provide feedback to

the patient while learning the new exercises. In

addition, it may also involve the skills of a

therapist to ensure patient safety during the

performance of the exercise such as maintaining a

fractured extremity in proper alignment during the

performance of the exercise. In addition, therapeutic

exercise involves the establishment and progression of

a home exercise program related to ROM, flexibility,

and strengthening. Once the patient can perform the

exercises safely and independently and no longer

requires the skills of a therapist, you do not bill

for that time. Other skills of a therapist may be

monitoring heart rate, blood presuure, pulse ox,

taking measurements pre and post exercise, etc.

This is no different than any other one-on-one

intervention you bill such as neuromuscular

re-education or therapeutic activities, of which you

mentioned. Once the patient can perform these

interventions independently and no longer requires the

skills of a therapist, you don't bill for that time.

What makes these interventions require more skills of

a therapist than therapeutic exercise? It is dependent

on the skill level of the therapist and/or assistant

and the needs of the patient.

Patients can learn to perform the Baps Board, the Body

Blade, dynamic functional activities, etc., just as

easy as therapeutic exercises some of the time and

vice versa may also be true.

What does the patient need? What did you provide? Is

it skilled? How much time did you spend providing each

timed skilled service? Once you have these answers,

bill for your services.

Rick Gawenda, PT

President, Section on Health policy & Administration

APTA

--- keith bisesi wrote:

> That's exactly my point. But involved activities

> like

> those should be billed therapeutic activity or neuro

> re-ed. Obviously a skilled technique, such as

> manually applied PNF patterns or hold relax etc,

> even

> just simple AAROM require more skill than teaching

> someone bridging and counting 3 sets of 10 with

> them.

> Why should these be held to the same

> contact/interaction standards by the AMA's CPT

> coding?

>

> Bisesi MPT COMT.

> Winter Haven, FL

>

>

> --- Jim wrote:

>

> > ,

> >

> > Doesn't that depend on what kind of ther. ex.

> > you're talking about. Example: Using a PNF

> > techniques like slow reversal, hold, relax would

> be

> > one on one.

> > Jim Arceneaux, LOTR

> >

> > keith bisesi wrote:

> > ,

> >

> > I am one of the posters who stated that

> therapeutic

> > exercise should not require one on one contact. I

> > probably should not have been so vague. I still

> > strongly feel that therapeutic exercise should not

> > have a one on one PT contact requirement. The ther

> > ex

> > procedure should not be held to the same contact

> > requirements as a therapeutic activity or neuro

> > re-ed

> > procedure that warrants our interaction 100% of

> the

> > billable treatment time. Activities falling under

> > ther

> > ex are no where near as skilled a service as a

> > therapeutic activity or neuro re-ed activity. With

> > ther ex, the skill is in the exercise

> prescription,

> > the teaching of the mechanics, the assessment of

> > patient performance with correct mechanics, and

> the

> > patient response to the exercise set. Ther ex does

> > not

> > require our skills for " 3 sets of 10. " Ther

> activity

> > and neuro re-ed usually warrant our constant

> > interaction. Ther ex should be able to be billed

> for

> > more than one person at a time, or we should only

> be

> > able to bill for the time during the exercise

> > session

> > that requires our instruction and monitoring.

> > Patients

> > do not need our constant monitoring after we

> > demonstrate a new exercise, then after perhaps 5

> > reps

> > demonstrate correct mechanics. The patient doesn't

> > need us again until they finish and we assess

> > response.

> >

> > Bisesi MPT COMT

> > Winter Haven, FL

> >

> > --- thomas m howell wrote:

> >

> > > Hi Larry,

> > >

> > >

> > >

> > > In regards to your thoughts later in your post.

> > >

> > >

> > >

> > > At my clinic (2 PT’s) that has been in business

> > for

> > > 9 years, we have never

> > > used a PTA or and aide for any part of

> treatment.

> > > Our aide functions

> > > exclusively for set up and break down after

> > > treatment (in addition to other

> > > clinic tasks). We do this even though our state

> > > practice act allows aides

> > > to do “treatment tasks”. So yes, 100% of our

> > > billing for 9 years has been

> > > done by a PT. (Please note we have nothing

> against

> > > PTA’s doing treatment

> > > they are licensed to do)

> > >

> > >

> > >

> > > We feel strongly that patients are coming to our

> > > clinic to see a PT, not a

> > > care extender. The contract we sign with

> > insurances

> > > are between us as PT’s

> > > and the insurance and they are expecting their

> > > beneficiaries to be seen by a

> > > PT. Now, I know many will argue this point in

> the

> > > sake of having a

> > > profitable clinic, which is fine. I think the

> > > debate must continue. Our

> > > clinic choice is a personal choice, but one

> which

> > we

> > > feel is in the best

> > > interests of our clients. They come to our

> clinic

> > > to see us, not an aide

> > > and our standing in the community is growing

> > because

> > > of that commitment.

> > > This commitment makes billing a lot less

> > complicated

> > > to do as well because

> > > we bill for the time and procedures we do.

> > >

> > >

> > >

> > > I also cringed after seeing other posts that

> seem

> > to

> > > blow off the need and

> > > input of a PT, such as saying that therapeutic

> > > exercise doesn’t really need

> > > the one-on one intervention of a PT. It

> diminishes

> > > our profession. Why do

> > > you think patients are given exercise sheet or

> > told

> > > to see a personal

> > > trainer for exercise instead of a PT? In part

> > > because we diminish our own

> > > need instead of promoting our expertise.

> > >

> > >

> > >

> > > Just my opinion for today.

> > >

> > >

> > >

> > > Tom Howell, P.T., M.P.T.

> > >

> > > Howell Physical Therapy

> > >

> > > Eagle, ID

> > >

> > > howellpt@...

> > >

> > >

> > >

> > > _____

> > >

> > > From: PTManager

> > > [mailto:PTManager ] On Behalf

> > > Of Larry Benz

> > > Sent: Wednesday, April 16, 2008 5:53 AM

> > > To: PTManager

> > > Subject: RE: One- on- One Treatment

> > for

> > > Medicare vs.

> > > Non-Medicare patients

> > >

> > >

> > >

> > > Jim:

> > >

> > > Great comment.

> > >

> > > While respecting you fully Mark, I don't believe

> > the

> > > issue is as cut and

> > > dried as you and some others might think. Let's

> > put

> > > medicare completely to

> > > the side on this since it has been aptly pointed

> > out

> > > that the definitions of

> > > the CPT codes are not Medicare's. There are few

> > > other payors in my

> > > experience (and I acknowledge that this is

> > different

> > > in different markets)

> > > that explicitly state who are qualified

> providers.

> > > With medicare, they are

> > > very explicit-has to be a PT or a PTA (the

>

=== message truncated ===

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[Guest guest]

,

I would have to say that would be being intentionally fraudulent,

you would be telling medicare that yes, I treated this patient one

on one, when, in fact you hadn't, with the theory being that they

would have no way to track this, so its not fraud. Doesnt make

sense to me, and remember, patients are becoming more and more aware

of the rules and regs, lets say one of your medicare patients gets

their EOB that says they were billed x amount, they then learn that

that x amount should only be billed for one on one care, they know

that you were seeing another, younger person at the same time, they

call the 1- 800 fraud number on the envelope from the EOB, boom your

done, not worth the risk.

E. s, PT, DPT

Orthopedic Clinical Specialist

Fellow American Acadamy Orthopedic Manual Physical Therapists

www.douglasspt.com

>

> Group,

>

> I know this has been discussed in the past, but it has become a

matter of discussion between my partner and I. My partner is not a

PT and looks at numbers only, not numbers and patient care like me.

>

> Here is the issue- During doubled up treatment slots when we are

treating under the " one on one " rule from CMS, meaning the

individual times equal the total treatment time for both patients,

is it mandatory to apply this same CMS rule to non-Medicare

patients?

>

> It seems ethical to apply the rule for both patients, but my

partner wants to " push the envelope " and not apply the one on one

rule to the non-Medicare patients for the sake of the bottom line.

Thus I would be coding my units as if I was seeing both patients on

an individual basis. Am I being unintentionally fraudulent with the

non-Medicare contractors?

>

> Thanks in advance,

> Hankins, PT/President

> Synergy Therapies, LLC

>

>

>

>

[Guest guest]

Tom,

we are now in year 6, all treatments have been billed by PT only, no

assistants or aides. I have also been asked many times why I dont

hire a PTA and my answer is the same as yours, we do our best to

attract and hire the best PT's, our patients would not stand for

care extenders, it is what sets us apart from our competition

locally. My belief is that our profession utilizes these care

extenders, just as docs utilize ARNP's, PA's and medical assistants

to 'dumb down' to the level of reimbursement from medicare and

insurance companies, maybe, just maybe, if we had all refused to

devalue the care that we give and instead had passed the cost along

to the patient by refusing to accept the insurance companies

contracts, healthcare in this country wouldnt be in the mess that it

is now. We are in the process of dumping any contract that doesnt

at least meet the cost of our doing business the way we want to do

business and the way our patients want us to do business, meaning no

techs, aides or assistants. I'll let you know how it goes.

E. s, PT, DPT

Orthopedic Clinical Specialist

Fellow American Acadamy Orhtopedic Manual Physical Therapists

www.douglasspt.com

>

> Hi Larry,

>

>

>

> In regards to your thoughts later in your post.

>

>

>

> At my clinic (2 PT's) that has been in business for 9 years, we

have never

> used a PTA or and aide for any part of treatment. Our aide

functions

> exclusively for set up and break down after treatment (in addition

to other

> clinic tasks). We do this even though our state practice act

allows aides

> to do " treatment tasks " . So yes, 100% of our billing for 9 years

has been

> done by a PT. (Please note we have nothing against PTA's doing

treatment

> they are licensed to do)

>

>

>

> We feel strongly that patients are coming to our clinic to see a

PT, not a

> care extender. The contract we sign with insurances are between

us as PT's

> and the insurance and they are expecting their beneficiaries to be

seen by a

> PT. Now, I know many will argue this point in the sake of having a

> profitable clinic, which is fine. I think the debate must

continue. Our

> clinic choice is a personal choice, but one which we feel is in

the best

> interests of our clients. They come to our clinic to see us, not

an aide

> and our standing in the community is growing because of that

commitment.

> This commitment makes billing a lot less complicated to do as well

because

> we bill for the time and procedures we do.

>

>

>

> I also cringed after seeing other posts that seem to blow off the

need and

> input of a PT, such as saying that therapeutic exercise doesn't

really need

> the one-on one intervention of a PT. It diminishes our

profession. Why do

> you think patients are given exercise sheet or told to see a

personal

> trainer for exercise instead of a PT? In part because we diminish

our own

> need instead of promoting our expertise.

>

>

>

> Just my opinion for today.

>

>

>

> Tom Howell, P.T., M.P.T.

>

> Howell Physical Therapy

>

> Eagle, ID

>

> howellpt@...

>

>

>

> _____

>

> From: PTManager [mailto:PTManager ]

On Behalf

> Of Larry Benz

> Sent: Wednesday, April 16, 2008 5:53 AM

> To: PTManager

> Subject: RE: One- on- One Treatment for Medicare vs.

> Non-Medicare patients

>

>

>

> Jim:

>

> Great comment.

>

> While respecting you fully Mark, I don't believe the issue is as

cut and

> dried as you and some others might think. Let's put medicare

completely to

> the side on this since it has been aptly pointed out that the

definitions of

> the CPT codes are not Medicare's. There are few other payors in my

> experience (and I acknowledge that this is different in different

markets)

> that explicitly state who are qualified providers. With medicare,

they are

> very explicit-has to be a PT or a PTA (the inconsistency on the

PTA in

> regards to setting is crazy but that is a different matter

altogether).

>

> In fact, most defer to state practice acts which although

different, allow

> delegation of some tasks to extenders under supervision. This

implies that

> the services are rendered by the PT. In the case of overlapping

patients and

> the use of extenders for some patients (e.g. therapeutic exercise

one on

> one) isn't practically violated as long as the supervision and

state

> practice act is being upheld.

>

> This isn't any different than the surgical codes, office visits,

or for that

> matter the injection codes for a physician who obviously delegates

> components to an extender (easy example is the office visit where

blood

> pressure is done by nurse). The MD codes the evaluation and is

responsible

> for it but to believe they did every portion literally themselves

is

> ridiculous.

>

> My point is not to argue whether exclusive one on one by a PT is

the best or

> preferred practice model but to point out that the interpretation

of the

> code is not as explicit as a faction of the PT's in our profession

believe

> (and are taught by many). I can honestly see where the quite

literal

> translation of that CPT code can be done and I believe that for

the purposes

> of clarification that it should be edited (specifically things

like ther ex

> might be better served with a modifier in supervised cases-just a

thought

> realizing that it has all kinds of implications). In fact, I think

that our

> codes and the whole time vs. service base while serving us well

with its

> transition in the mid 90's is now a thing of the past and should

be scrapped

> for PT services and replaced with office visits. Lastly on this

point, my

> experience in viewing practice patterns in for profit, non profit,

public,

> and other outpatient clinics supports the notion that PT's do in

fact

> delegate tasks (again non federally funded patients) and uphold

their

> practice act. Yes, there are abusers of it and when they abuse in

my

> experience is that they aren't following the supervision

guidelines which

> are typically explicit in practice acts. Some might argue that

just because

> the prevailing mainstream practices, delegate tasks doesn't make

it right or

> uphold the CPT code definition (which they quite parochially

interpret). On

> this point I also disagree as I have seen much in case law (I am

not an

> attorney and don't play one on TV) based upon prevailing practice.

How many

> on this list serve can honestly state that 100% of all tasks that

are billed

> are 100% of the time rendered by a PT or a PTA?

>

> The other aspect of this that I find appalling is that the whole

transition

> to autonomous practitioner flies in the face of the notion that a

PT cannot

> delegate. The only thing that rightfully matters is that the

patient is

> under care of a PT and that outcome is of the prime factor. Time

based codes

> imply that more is better (at least from a payment standpoint)

when we know

> that many of the most efficacious interventions don't hold that

tenant.

>

> Please also understand that my point is also not to debate this

whole thing

> in terms of " I am right you are wrong " but to at least point out

that the

> interpretation is not as one way as many point out and the

prevailing

> practice patterns do in fact have overlapping patients which are

often times

> handled appropriately with supervision of a PT.

>

> __________________________________________

>

> Larry

>

> Larry Benz

>

> PT Development LLC

>

> 13000 Equity Place Suite 105

>

> Louisville, KY 40223

>

> larry@physicalthera <mailto:larry%40physicaltherapist.com>

pist.com (best

> way to reach)

>

> mobile (Spinvox converts voice to email)

>

> office

>

> (Fax: only if you must)

>

> LarryBenz MyPhysicalTherapySpace.com ID

>

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ps.com

> [mailto:PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com>

ps.com] On

> Behalf Of JHall49629aol (DOT) <mailto:JHall49629%40aol.com> com

> Sent: Tuesday, April 15, 2008 10:06 PM

> To: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

> Subject: Re: One- on- One Treatment for Medicare vs.

> Non-Medicare patients

>

> In a message dated 4/15/2008 6:31:20 A.M. Central Daylight Time,

> mschwallcomcast (DOT) <mailto:mschwall%40comcast.net> net

> <mailto:mschwall%40comcast.net> writes:

>

> Also as an observation and purely editorial comment I always find

it

> interesting that those who have no particular accountability due

to being a

> non-licensed " owner " always seem to be the most willing to " push

the

> envelope " with respect to billing and reimbursement behaviors. Do

we need

> any more evidence that ownership of Physical Therapy services

should be

> strictly limited to only licensed Physical Therapists? How long

are we, as

> licensees, going to continue to be willing to be accountable for

the conduct

> of those who cannot be held accountable?

>

> Mark

>

> Interesting observation. I think it is easy to see publicly traded

Physical

> Therapy company's with unscrupulous NON PT's as the head creating

problems.

> It is easy to think that PT's are not involved in the problem. But

as Lee

> Corso the ESPN Football Analyst says, " NOT SO FAST MY FRIEND! " I

worked in a

>

> couple of privately held and one publicly traded PT Company. As

this

> company's Director of Internal Audit, I can tell you that I

performed fraud

> investigations on PT's that we incorrectly coding services and

stealing from

> my

> employer. As a CPA, I have read about some of the largest fraud

cases being

> perpetrated or assisted by CPA's. CPA Firms used to limit

ownership to

> strictly

> CPA's for some of the reasons you are alluding to in your post. My

point is

> that it doesn't matter whether you are a PT, a respiratory

therapist (of a

> publicly traded company), a CPA or a stay at home caretaker. If

you are

> willing

> to cheat/beat the system, you will. If you are interested in

working an

> honest days work for an honest days wage-you do. It doesn't matter

what

> position/status you carry in life, your character is what counts.

Just

> because you

> are a PT or a CPA doesn't mean you have character, that comes from

within.

>

> Jim Hall, CPA <///><

> General Manager

> Rehab Management Services, LLC

> Cedar Rapids, IA

> 319/892-0142

>

> **************It's Tax Time! Get tips, forms and advice on AOL

Money &

> Finance. (http://money. <http://money.aol.com/tax?

NCID=aolcmp00300000002850>

> aol.com/tax?NCID=aolcmp00300000002850 <http://money.

> <http://money.aol.com/tax?NCID=aolcmp00300000002850>

> aol.com/tax?NCID=aolcmp00300000002850> )

>

>

[Guest guest]

Is it acceptable to include minutes spent taking ROM measurements,

manual muscle testing, etc. into the theraputic exercise code (97110)?

Valdes, PT, OCS, cert MDT

Lakeland Health Care

St. ph, MI

>>> Rick Gawenda 04/17/2008 11:20:24 PM >>>

Therapeutic exercise is a one-on-one direct contact

CPT code because it requires the skills of a

therapist, or an assistant under the supervision of a

therapist, to teach, educate, and provide feedback to

the patient while learning the new exercises. In

addition, it may also involve the skills of a

therapist to ensure patient safety during the

performance of the exercise such as maintaining a

fractured extremity in proper alignment during the

performance of the exercise. In addition, therapeutic

exercise involves the establishment and progression of

a home exercise program related to ROM, flexibility,

and strengthening. Once the patient can perform the

exercises safely and independently and no longer

requires the skills of a therapist, you do not bill

for that time. Other skills of a therapist may be

monitoring heart rate, blood presuure, pulse ox,

taking measurements pre and post exercise, etc.

This is no different than any other one-on-one

intervention you bill such as neuromuscular

re-education or therapeutic activities, of which you

mentioned. Once the patient can perform these

interventions independently and no longer requires the

skills of a therapist, you don't bill for that time.

What makes these interventions require more skills of

a therapist than therapeutic exercise? It is dependent

on the skill level of the therapist and/or assistant

and the needs of the patient.

Patients can learn to perform the Baps Board, the Body

Blade, dynamic functional activities, etc., just as

easy as therapeutic exercises some of the time and

vice versa may also be true.

What does the patient need? What did you provide? Is

it skilled? How much time did you spend providing each

timed skilled service? Once you have these answers,

bill for your services.

Rick Gawenda, PT

President, Section on Health policy & Administration

APTA

--- keith bisesi wrote:

> That's exactly my point. But involved activities

> like

> those should be billed therapeutic activity or neuro

> re-ed. Obviously a skilled technique, such as

> manually applied PNF patterns or hold relax etc,

> even

> just simple AAROM require more skill than teaching

> someone bridging and counting 3 sets of 10 with

> them.

> Why should these be held to the same

> contact/interaction standards by the AMA's CPT

> coding?

>

> Bisesi MPT COMT.

> Winter Haven, FL

>

>

> --- Jim wrote:

>

> > ,

> >

> > Doesn't that depend on what kind of ther. ex.

> > you're talking about. Example: Using a PNF

> > techniques like slow reversal, hold, relax would

> be

> > one on one.

> > Jim Arceneaux, LOTR

> >

> > keith bisesi wrote:

> > ,

> >

> > I am one of the posters who stated that

> therapeutic

> > exercise should not require one on one contact. I

> > probably should not have been so vague. I still

> > strongly feel that therapeutic exercise should not

> > have a one on one PT contact requirement. The ther

> > ex

> > procedure should not be held to the same contact

> > requirements as a therapeutic activity or neuro

> > re-ed

> > procedure that warrants our interaction 100% of

> the

> > billable treatment time. Activities falling under

> > ther

> > ex are no where near as skilled a service as a

> > therapeutic activity or neuro re-ed activity. With

> > ther ex, the skill is in the exercise

> prescription,

> > the teaching of the mechanics, the assessment of

> > patient performance with correct mechanics, and

> the

> > patient response to the exercise set. Ther ex does

> > not

> > require our skills for " 3 sets of 10. " Ther

> activity

> > and neuro re-ed usually warrant our constant

> > interaction. Ther ex should be able to be billed

> for

> > more than one person at a time, or we should only

> be

> > able to bill for the time during the exercise

> > session

> > that requires our instruction and monitoring.

> > Patients

> > do not need our constant monitoring after we

> > demonstrate a new exercise, then after perhaps 5

> > reps

> > demonstrate correct mechanics. The patient doesn't

> > need us again until they finish and we assess

> > response.

> >

> > Bisesi MPT COMT

> > Winter Haven, FL

> >

> > --- thomas m howell wrote:

> >

> > > Hi Larry,

> > >

> > >

> > >

> > > In regards to your thoughts later in your post.

> > >

> > >

> > >

> > > At my clinic (2 PT’s) that has been in business

> > for

> > > 9 years, we have never

> > > used a PTA or and aide for any part of

> treatment.

> > > Our aide functions

> > > exclusively for set up and break down after

> > > treatment (in addition to other

> > > clinic tasks). We do this even though our state

> > > practice act allows aides

> > > to do “treatment tasksâ€. So yes, 100% of our

> > > billing for 9 years has been

> > > done by a PT. (Please note we have nothing

> against

> > > PTA’s doing treatment

> > > they are licensed to do)

> > >

> > >

> > >

> > > We feel strongly that patients are coming to our

> > > clinic to see a PT, not a

> > > care extender. The contract we sign with

> > insurances

> > > are between us as PT’s

> > > and the insurance and they are expecting their

> > > beneficiaries to be seen by a

> > > PT. Now, I know many will argue this point in

> the

> > > sake of having a

> > > profitable clinic, which is fine. I think the

> > > debate must continue. Our

> > > clinic choice is a personal choice, but one

> which

> > we

> > > feel is in the best

> > > interests of our clients. They come to our

> clinic

> > > to see us, not an aide

> > > and our standing in the community is growing

> > because

> > > of that commitment.

> > > This commitment makes billing a lot less

> > complicated

> > > to do as well because

> > > we bill for the time and procedures we do.

> > >

> > >

> > >

> > > I also cringed after seeing other posts that

> seem

> > to

> > > blow off the need and

> > > input of a PT, such as saying that therapeutic

> > > exercise doesn’t really need

> > > the one-on one intervention of a PT. It

> diminishes

> > > our profession. Why do

> > > you think patients are given exercise sheet or

> > told

> > > to see a personal

> > > trainer for exercise instead of a PT? In part

> > > because we diminish our own

> > > need instead of promoting our expertise.

> > >

> > >

> > >

> > > Just my opinion for today.

> > >

> > >

> > >

> > > Tom Howell, P.T., M.P.T.

> > >

> > > Howell Physical Therapy

> > >

> > > Eagle, ID

> > >

> > > howellpt@...

> > >

> > >

> > >

> > > _____

> > >

> > > From: PTManager

> > > [mailto:PTManager ] On Behalf

> > > Of Larry Benz

> > > Sent: Wednesday, April 16, 2008 5:53 AM

> > > To: PTManager

> > > Subject: RE: One- on- One Treatment

> > for

> > > Medicare vs.

> > > Non-Medicare patients

> > >

> > >

> > >

> > > Jim:

> > >

> > > Great comment.

> > >

> > > While respecting you fully Mark, I don't believe

> > the

> > > issue is as cut and

> > > dried as you and some others might think. Let's

> > put

> > > medicare completely to

> > > the side on this since it has been aptly pointed

> > out

> > > that the definitions of

> > > the CPT codes are not Medicare's. There are few

> > > other payors in my

> > > experience (and I acknowledge that this is

> > different

> > > in different markets)

> > > that explicitly state who are qualified

> providers.

> > > With medicare, they are

> > > very explicit-has to be a PT or a PTA (the

>

=== message truncated ===

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[Guest guest]

Thank you Rick for more eloquently stating what I was trying to!

Come on everybody! I still haven't heard many suggestions and solutions to

the CPT debate and in response to some suggestions that I made. This is a

great opportunity to discuss what changes we would like to see (if any) to

the CPT system. Let's use this opportunity for creative change!

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of Rick Gawenda

Sent: Thursday, April 17, 2008 9:20 PM

To: PTManager

Subject: RE: One- on- One Treatment for Medicare vs.

Non-Medicare patients

Therapeutic exercise is a one-on-one direct contact

CPT code because it requires the skills of a

therapist, or an assistant under the supervision of a

therapist, to teach, educate, and provide feedback to

the patient while learning the new exercises. In

addition, it may also involve the skills of a

therapist to ensure patient safety during the

performance of the exercise such as maintaining a

fractured extremity in proper alignment during the

performance of the exercise. In addition, therapeutic

exercise involves the establishment and progression of

a home exercise program related to ROM, flexibility,

and strengthening. Once the patient can perform the

exercises safely and independently and no longer

requires the skills of a therapist, you do not bill

for that time. Other skills of a therapist may be

monitoring heart rate, blood presuure, pulse ox,

taking measurements pre and post exercise, etc.

This is no different than any other one-on-one

intervention you bill such as neuromuscular

re-education or therapeutic activities, of which you

mentioned. Once the patient can perform these

interventions independently and no longer requires the

skills of a therapist, you don't bill for that time.

What makes these interventions require more skills of

a therapist than therapeutic exercise? It is dependent

on the skill level of the therapist and/or assistant

and the needs of the patient.

Patients can learn to perform the Baps Board, the Body

Blade, dynamic functional activities, etc., just as

easy as therapeutic exercises some of the time and

vice versa may also be true.

What does the patient need? What did you provide? Is

it skilled? How much time did you spend providing each

timed skilled service? Once you have these answers,

bill for your services.

Rick Gawenda, PT

President, Section on Health policy & Administration

APTA

--- keith bisesi <kbisesiyahoo (DOT) <mailto:kbisesi%40yahoo.com> com> wrote:

> That's exactly my point. But involved activities

> like

> those should be billed therapeutic activity or neuro

> re-ed. Obviously a skilled technique, such as

> manually applied PNF patterns or hold relax etc,

> even

> just simple AAROM require more skill than teaching

> someone bridging and counting 3 sets of 10 with

> them.

> Why should these be held to the same

> contact/interaction standards by the AMA's CPT

> coding?

>

> Bisesi MPT COMT.

> Winter Haven, FL

>

>

> --- Jim <jimpalestine@ <mailto:jimpalestine%40yahoo.com> yahoo.com> wrote:

>

> > ,

> >

> > Doesn't that depend on what kind of ther. ex.

> > you're talking about. Example: Using a PNF

> > techniques like slow reversal, hold, relax would

> be

> > one on one.

> > Jim Arceneaux, LOTR

> >

> > keith bisesi <kbisesiyahoo (DOT) <mailto:kbisesi%40yahoo.com> com> wrote:

> > ,

> >

> > I am one of the posters who stated that

> therapeutic

> > exercise should not require one on one contact. I

> > probably should not have been so vague. I still

> > strongly feel that therapeutic exercise should not

> > have a one on one PT contact requirement. The ther

> > ex

> > procedure should not be held to the same contact

> > requirements as a therapeutic activity or neuro

> > re-ed

> > procedure that warrants our interaction 100% of

> the

> > billable treatment time. Activities falling under

> > ther

> > ex are no where near as skilled a service as a

> > therapeutic activity or neuro re-ed activity. With

> > ther ex, the skill is in the exercise

> prescription,

> > the teaching of the mechanics, the assessment of

> > patient performance with correct mechanics, and

> the

> > patient response to the exercise set. Ther ex does

> > not

> > require our skills for " 3 sets of 10. " Ther

> activity

> > and neuro re-ed usually warrant our constant

> > interaction. Ther ex should be able to be billed

> for

> > more than one person at a time, or we should only

> be

> > able to bill for the time during the exercise

> > session

> > that requires our instruction and monitoring.

> > Patients

> > do not need our constant monitoring after we

> > demonstrate a new exercise, then after perhaps 5

> > reps

> > demonstrate correct mechanics. The patient doesn't

> > need us again until they finish and we assess

> > response.

> >

> > Bisesi MPT COMT

> > Winter Haven, FL

> >

> > --- thomas m howell <thowellfiberpipe (DOT) <mailto:thowell%40fiberpipe.net>

net> wrote:

> >

> > > Hi Larry,

> > >

> > >

> > >

> > > In regards to your thoughts later in your post.

> > >

> > >

> > >

> > > At my clinic (2 PT's) that has been in business

> > for

> > > 9 years, we have never

> > > used a PTA or and aide for any part of

> treatment.

> > > Our aide functions

> > > exclusively for set up and break down after

> > > treatment (in addition to other

> > > clinic tasks). We do this even though our state

> > > practice act allows aides

> > > to do " treatment tasks " . So yes, 100% of our

> > > billing for 9 years has been

> > > done by a PT. (Please note we have nothing

> against

> > > PTA's doing treatment

> > > they are licensed to do)

> > >

> > >

> > >

> > > We feel strongly that patients are coming to our

> > > clinic to see a PT, not a

> > > care extender. The contract we sign with

> > insurances

> > > are between us as PT's

> > > and the insurance and they are expecting their

> > > beneficiaries to be seen by a

> > > PT. Now, I know many will argue this point in

> the

> > > sake of having a

> > > profitable clinic, which is fine. I think the

> > > debate must continue. Our

> > > clinic choice is a personal choice, but one

> which

> > we

> > > feel is in the best

> > > interests of our clients. They come to our

> clinic

> > > to see us, not an aide

> > > and our standing in the community is growing

> > because

> > > of that commitment.

> > > This commitment makes billing a lot less

> > complicated

> > > to do as well because

> > > we bill for the time and procedures we do.

> > >

> > >

> > >

> > > I also cringed after seeing other posts that

> seem

> > to

> > > blow off the need and

> > > input of a PT, such as saying that therapeutic

> > > exercise doesn't really need

> > > the one-on one intervention of a PT. It

> diminishes

> > > our profession. Why do

> > > you think patients are given exercise sheet or

> > told

> > > to see a personal

> > > trainer for exercise instead of a PT? In part

> > > because we diminish our own

> > > need instead of promoting our expertise.

> > >

> > >

> > >

> > > Just my opinion for today.

> > >

> > >

> > >

> > > Tom Howell, P.T., M.P.T.

> > >

> > > Howell Physical Therapy

> > >

> > > Eagle, ID

> > >

> > > howellptfiberpipe (DOT) <mailto:howellpt%40fiberpipe.net> net

> > >

> > >

> > >

> > > _____

> > >

> > > From: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

> > > [mailto:PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com>

ps.com] On Behalf

> > > Of Larry Benz

> > > Sent: Wednesday, April 16, 2008 5:53 AM

> > > To: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com

> > > Subject: RE: One- on- One Treatment

> > for

> > > Medicare vs.

> > > Non-Medicare patients

> > >

> > >

> > >

> > > Jim:

> > >

> > > Great comment.

> > >

> > > While respecting you fully Mark, I don't believe

> > the

> > > issue is as cut and

> > > dried as you and some others might think. Let's

> > put

> > > medicare completely to

> > > the side on this since it has been aptly pointed

> > out

> > > that the definitions of

> > > the CPT codes are not Medicare's. There are few

> > > other payors in my

> > > experience (and I acknowledge that this is

> > different

> > > in different markets)

> > > that explicitly state who are qualified

> providers.

> > > With medicare, they are

> > > very explicit-has to be a PT or a PTA (the

>

=== message truncated ===

__________________________________________________________

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[Guest guest]

That is part of your assessment which is included in

the interventions that you provide which is part of

the pre and post treatment. That is skilled therapy

that unqualified personnel can't perform.

Rick Gawenda, PT

President, Section on Health Policy & Administration

APTA

--- " W. Valdes "

wrote:

> Is it acceptable to include minutes spent taking ROM

> measurements,

> manual muscle testing, etc. into the theraputic

> exercise code (97110)?

>

> Valdes, PT, OCS, cert MDT

> Lakeland Health Care

> St. ph, MI

>

> >>> Rick Gawenda 04/17/2008

> 11:20:24 PM >>>

> Therapeutic exercise is a one-on-one direct contact

> CPT code because it requires the skills of a

> therapist, or an assistant under the supervision of

> a

> therapist, to teach, educate, and provide feedback

> to

> the patient while learning the new exercises. In

> addition, it may also involve the skills of a

> therapist to ensure patient safety during the

> performance of the exercise such as maintaining a

> fractured extremity in proper alignment during the

> performance of the exercise. In addition,

> therapeutic

> exercise involves the establishment and progression

> of

> a home exercise program related to ROM, flexibility,

> and strengthening. Once the patient can perform the

> exercises safely and independently and no longer

> requires the skills of a therapist, you do not bill

> for that time. Other skills of a therapist may be

> monitoring heart rate, blood presuure, pulse ox,

> taking measurements pre and post exercise, etc.

>

> This is no different than any other one-on-one

> intervention you bill such as neuromuscular

> re-education or therapeutic activities, of which you

> mentioned. Once the patient can perform these

> interventions independently and no longer requires

> the

> skills of a therapist, you don't bill for that time.

> What makes these interventions require more skills

> of

> a therapist than therapeutic exercise? It is

> dependent

> on the skill level of the therapist and/or assistant

> and the needs of the patient.

>

> Patients can learn to perform the Baps Board, the

> Body

> Blade, dynamic functional activities, etc., just as

> easy as therapeutic exercises some of the time and

> vice versa may also be true.

>

> What does the patient need? What did you provide? Is

> it skilled? How much time did you spend providing

> each

> timed skilled service? Once you have these answers,

> bill for your services.

>

> Rick Gawenda, PT

> President, Section on Health policy & Administration

> APTA

>

>

> --- keith bisesi wrote:

>

> > That's exactly my point. But involved activities

> > like

> > those should be billed therapeutic activity or

> neuro

> > re-ed. Obviously a skilled technique, such as

> > manually applied PNF patterns or hold relax etc,

> > even

> > just simple AAROM require more skill than teaching

> > someone bridging and counting 3 sets of 10 with

> > them.

> > Why should these be held to the same

> > contact/interaction standards by the AMA's CPT

> > coding?

> >

> > Bisesi MPT COMT.

> > Winter Haven, FL

> >

> >

> > --- Jim wrote:

> >

> > > ,

> > >

> > > Doesn't that depend on what kind of ther. ex.

> > > you're talking about. Example: Using a PNF

> > > techniques like slow reversal, hold, relax would

> > be

> > > one on one.

> > > Jim Arceneaux, LOTR

> > >

> > > keith bisesi wrote:

> > > ,

> > >

> > > I am one of the posters who stated that

> > therapeutic

> > > exercise should not require one on one contact.

> I

> > > probably should not have been so vague. I still

> > > strongly feel that therapeutic exercise should

> not

> > > have a one on one PT contact requirement. The

> ther

> > > ex

> > > procedure should not be held to the same contact

> > > requirements as a therapeutic activity or neuro

> > > re-ed

> > > procedure that warrants our interaction 100% of

> > the

> > > billable treatment time. Activities falling

> under

> > > ther

> > > ex are no where near as skilled a service as a

> > > therapeutic activity or neuro re-ed activity.

> With

> > > ther ex, the skill is in the exercise

> > prescription,

> > > the teaching of the mechanics, the assessment of

> > > patient performance with correct mechanics, and

> > the

> > > patient response to the exercise set. Ther ex

> does

> > > not

> > > require our skills for " 3 sets of 10. " Ther

> > activity

> > > and neuro re-ed usually warrant our constant

> > > interaction. Ther ex should be able to be billed

> > for

> > > more than one person at a time, or we should

> only

> > be

> > > able to bill for the time during the exercise

> > > session

> > > that requires our instruction and monitoring.

> > > Patients

> > > do not need our constant monitoring after we

> > > demonstrate a new exercise, then after perhaps 5

> > > reps

> > > demonstrate correct mechanics. The patient

> doesn't

> > > need us again until they finish and we assess

> > > response.

> > >

> > > Bisesi MPT COMT

> > > Winter Haven, FL

> > >

> > > --- thomas m howell

> wrote:

> > >

> > > > Hi Larry,

> > > >

> > > >

> > > >

> > > > In regards to your thoughts later in your

> post.

> > > >

> > > >

> > > >

> > > > At my clinic (2 PT’s) that has been in

> business

> > > for

> > > > 9 years, we have never

> > > > used a PTA or and aide for any part of

> > treatment.

> > > > Our aide functions

> > > > exclusively for set up and break down after

> > > > treatment (in addition to other

> > > > clinic tasks). We do this even though our

> state

> > > > practice act allows aides

> > > > to do “treatment tasksâ€. So yes, 100% of

> our

> > > > billing for 9 years has been

> > > > done by a PT. (Please note we have nothing

> > against

> > > > PTA’s doing treatment

> > > > they are licensed to do)

> > > >

> > > >

> > > >

> > > > We feel strongly that patients are coming to

> our

> > > > clinic to see a PT, not a

> > > > care extender. The contract we sign with

> > > insurances

> > > > are between us as PT’s

> > > > and the insurance and they are expecting their

> > > > beneficiaries to be seen by a

> > > > PT. Now, I know many will argue this point in

> > the

> > > > sake of having a

> > > > profitable clinic, which is fine. I think the

> > > > debate must continue. Our

> > > > clinic choice is a personal choice, but one

> > which

> > > we

>

=== message truncated ===

________________________________________________________________________________\

____

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know-it-all with Yahoo! Mobile. Try it now.

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[Guest guest]

-Tom,

two simple examples I can think of right away deal with the language

of the CPT codes not keeping up with technology, ie unattended US and

iontophoresis patches, thanks for the great conversation.

E. s, PT, DPT

Orthopedic Clinical Specialist

Fellow American Academy of Orthopedic Manual Physical Therapists

www.douglasspt.com

-- In PTManager , " thomas m howell "

wrote:

>

> Thank you Rick for more eloquently stating what I was trying to!

>

>

>

> Come on everybody! I still haven't heard many suggestions and

solutions to

> the CPT debate and in response to some suggestions that I made.

This is a

> great opportunity to discuss what changes we would like to see (if

any) to

> the CPT system. Let's use this opportunity for creative change!

>

>

>

> Tom Howell, P.T., M.P.T.

>

> Howell Physical Therapy

>

> Eagle, ID

>

> howellpt@...

>

>

>

>

>

> _____

>

> From: PTManager [mailto:PTManager ]

On Behalf

> Of Rick Gawenda

> Sent: Thursday, April 17, 2008 9:20 PM

> To: PTManager

> Subject: RE: One- on- One Treatment for Medicare vs.

> Non-Medicare patients

>

>

>

> Therapeutic exercise is a one-on-one direct contact

> CPT code because it requires the skills of a

> therapist, or an assistant under the supervision of a

> therapist, to teach, educate, and provide feedback to

> the patient while learning the new exercises. In

> addition, it may also involve the skills of a

> therapist to ensure patient safety during the

> performance of the exercise such as maintaining a

> fractured extremity in proper alignment during the

> performance of the exercise. In addition, therapeutic

> exercise involves the establishment and progression of

> a home exercise program related to ROM, flexibility,

> and strengthening. Once the patient can perform the

> exercises safely and independently and no longer

> requires the skills of a therapist, you do not bill

> for that time. Other skills of a therapist may be

> monitoring heart rate, blood presuure, pulse ox,

> taking measurements pre and post exercise, etc.

>

> This is no different than any other one-on-one

> intervention you bill such as neuromuscular

> re-education or therapeutic activities, of which you

> mentioned. Once the patient can perform these

> interventions independently and no longer requires the

> skills of a therapist, you don't bill for that time.

> What makes these interventions require more skills of

> a therapist than therapeutic exercise? It is dependent

> on the skill level of the therapist and/or assistant

> and the needs of the patient.

>

> Patients can learn to perform the Baps Board, the Body

> Blade, dynamic functional activities, etc., just as

> easy as therapeutic exercises some of the time and

> vice versa may also be true.

>

> What does the patient need? What did you provide? Is

> it skilled? How much time did you spend providing each

> timed skilled service? Once you have these answers,

> bill for your services.

>

> Rick Gawenda, PT

> President, Section on Health policy & Administration

> APTA

>

> --- keith bisesi <kbisesiyahoo (DOT) <mailto:kbisesi%40yahoo.com> com>

wrote:

>

> > That's exactly my point. But involved activities

> > like

> > those should be billed therapeutic activity or neuro

> > re-ed. Obviously a skilled technique, such as

> > manually applied PNF patterns or hold relax etc,

> > even

> > just simple AAROM require more skill than teaching

> > someone bridging and counting 3 sets of 10 with

> > them.

> > Why should these be held to the same

> > contact/interaction standards by the AMA's CPT

> > coding?

> >

> > Bisesi MPT COMT.

> > Winter Haven, FL

> >

> >

> > --- Jim <jimpalestine@ <mailto:jimpalestine%40yahoo.com>

yahoo.com> wrote:

> >

> > > ,

> > >

> > > Doesn't that depend on what kind of ther. ex.

> > > you're talking about. Example: Using a PNF

> > > techniques like slow reversal, hold, relax would

> > be

> > > one on one.

> > > Jim Arceneaux, LOTR

> > >

> > > keith bisesi <kbisesiyahoo (DOT) <mailto:kbisesi%40yahoo.com> com>

wrote:

> > > ,

> > >

> > > I am one of the posters who stated that

> > therapeutic

> > > exercise should not require one on one contact. I

> > > probably should not have been so vague. I still

> > > strongly feel that therapeutic exercise should not

> > > have a one on one PT contact requirement. The ther

> > > ex

> > > procedure should not be held to the same contact

> > > requirements as a therapeutic activity or neuro

> > > re-ed

> > > procedure that warrants our interaction 100% of

> > the

> > > billable treatment time. Activities falling under

> > > ther

> > > ex are no where near as skilled a service as a

> > > therapeutic activity or neuro re-ed activity. With

> > > ther ex, the skill is in the exercise

> > prescription,

> > > the teaching of the mechanics, the assessment of

> > > patient performance with correct mechanics, and

> > the

> > > patient response to the exercise set. Ther ex does

> > > not

> > > require our skills for " 3 sets of 10. " Ther

> > activity

> > > and neuro re-ed usually warrant our constant

> > > interaction. Ther ex should be able to be billed

> > for

> > > more than one person at a time, or we should only

> > be

> > > able to bill for the time during the exercise

> > > session

> > > that requires our instruction and monitoring.

> > > Patients

> > > do not need our constant monitoring after we

> > > demonstrate a new exercise, then after perhaps 5

> > > reps

> > > demonstrate correct mechanics. The patient doesn't

> > > need us again until they finish and we assess

> > > response.

> > >

> > > Bisesi MPT COMT

> > > Winter Haven, FL

> > >

> > > --- thomas m howell <thowellfiberpipe (DOT) <mailto:thowell%

40fiberpipe.net>

> net> wrote:

> > >

> > > > Hi Larry,

> > > >

> > > >

> > > >

> > > > In regards to your thoughts later in your post.

> > > >

> > > >

> > > >

> > > > At my clinic (2 PT's) that has been in business

> > > for

> > > > 9 years, we have never

> > > > used a PTA or and aide for any part of

> > treatment.

> > > > Our aide functions

> > > > exclusively for set up and break down after

> > > > treatment (in addition to other

> > > > clinic tasks). We do this even though our state

> > > > practice act allows aides

> > > > to do " treatment tasks " . So yes, 100% of our

> > > > billing for 9 years has been

> > > > done by a PT. (Please note we have nothing

> > against

> > > > PTA's doing treatment

> > > > they are licensed to do)

> > > >

> > > >

> > > >

> > > > We feel strongly that patients are coming to our

> > > > clinic to see a PT, not a

> > > > care extender. The contract we sign with

> > > insurances

> > > > are between us as PT's

> > > > and the insurance and they are expecting their

> > > > beneficiaries to be seen by a

> > > > PT. Now, I know many will argue this point in

> > the

> > > > sake of having a

> > > > profitable clinic, which is fine. I think the

> > > > debate must continue. Our

> > > > clinic choice is a personal choice, but one

> > which

> > > we

> > > > feel is in the best

> > > > interests of our clients. They come to our

> > clinic

> > > > to see us, not an aide

> > > > and our standing in the community is growing

> > > because

> > > > of that commitment.

> > > > This commitment makes billing a lot less

> > > complicated

> > > > to do as well because

> > > > we bill for the time and procedures we do.

> > > >

> > > >

> > > >

> > > > I also cringed after seeing other posts that

> > seem

> > > to

> > > > blow off the need and

> > > > input of a PT, such as saying that therapeutic

> > > > exercise doesn't really need

> > > > the one-on one intervention of a PT. It

> > diminishes

> > > > our profession. Why do

> > > > you think patients are given exercise sheet or

> > > told

> > > > to see a personal

> > > > trainer for exercise instead of a PT? In part

> > > > because we diminish our own

> > > > need instead of promoting our expertise.

> > > >

> > > >

> > > >

> > > > Just my opinion for today.

> > > >

> > > >

> > > >

> > > > Tom Howell, P.T., M.P.T.

> > > >

> > > > Howell Physical Therapy

> > > >

> > > > Eagle, ID

> > > >

> > > > howellptfiberpipe (DOT) <mailto:howellpt%40fiberpipe.net> net

> > > >

> > > >

> > > >

> > > > _____

> > > >

> > > > From: PTManager@yahoogrou <mailto:PTManager%

40yahoogroups.com> ps.com

> > > > [mailto:PTManager@yahoogrou <mailto:PTManager%

40yahoogroups.com>

> ps.com] On Behalf

> > > > Of Larry Benz

> > > > Sent: Wednesday, April 16, 2008 5:53 AM

> > > > To: PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com>

ps.com

> > > > Subject: RE: One- on- One Treatment

> > > for

> > > > Medicare vs.

> > > > Non-Medicare patients

> > > >

> > > >

> > > >

> > > > Jim:

> > > >

> > > > Great comment.

> > > >

> > > > While respecting you fully Mark, I don't believe

> > > the

> > > > issue is as cut and

> > > > dried as you and some others might think. Let's

> > > put

> > > > medicare completely to

> > > > the side on this since it has been aptly pointed

> > > out

> > > > that the definitions of

> > > > the CPT codes are not Medicare's. There are few

> > > > other payors in my

> > > > experience (and I acknowledge that this is

> > > different

> > > > in different markets)

> > > > that explicitly state who are qualified

> > providers.

> > > > With medicare, they are

> > > > very explicit-has to be a PT or a PTA (the

> >

> === message truncated ===

>

> __________________________________________________________

> Be a better friend, newshound, and

> know-it-all with Yahoo! Mobile. Try it now. http://mobile.

> <http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

> yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

>

>

>

>

>

>

[Guest guest]

,

I would agree that it would be fraudulent to bill each Medicare pt individually,

but a more complicated ethical question is how to bill when one of those

patients has private insurance and the other is Medicare. Do you charge group

for the Medicare (if your facility even uses that code) or nothing during that

portion of the Medicare pt's time and then go on and charge the privately

insured patient for individual treatment as that payor may not have a one-on-one

guideline? It appears to me, based on the previous discussions on this topic,

that ther ex (97110) is the trump card anyway as it requires " direct,

one-on-one " service in order to be billable. Any thoughts?

Kanning, PT

OP Rehab Team Leader

Valdosta, GA

________________________________

From: PTManager on behalf of s

Sent: Fri 4/18/2008 7:48 AM

To: PTManager

Subject: Re: One- on- One Treatment for Medicare vs. Non-Medicare

patients

,

I would have to say that would be being intentionally fraudulent,

you would be telling medicare that yes, I treated this patient one

on one, when, in fact you hadn't, with the theory being that they

would have no way to track this, so its not fraud. Doesnt make

sense to me, and remember, patients are becoming more and more aware

of the rules and regs, lets say one of your medicare patients gets

their EOB that says they were billed x amount, they then learn that

that x amount should only be billed for one on one care, they know

that you were seeing another, younger person at the same time, they

call the 1- 800 fraud number on the envelope from the EOB, boom your

done, not worth the risk.

E. s, PT, DPT

Orthopedic Clinical Specialist

Fellow American Acadamy Orthopedic Manual Physical Therapists

www.douglasspt.com

>

> Group,

>

> I know this has been discussed in the past, but it has become a

matter of discussion between my partner and I. My partner is not a

PT and looks at numbers only, not numbers and patient care like me.

>

> Here is the issue- During doubled up treatment slots when we are

treating under the " one on one " rule from CMS, meaning the

individual times equal the total treatment time for both patients,

is it mandatory to apply this same CMS rule to non-Medicare

patients?

>

> It seems ethical to apply the rule for both patients, but my

partner wants to " push the envelope " and not apply the one on one

rule to the non-Medicare patients for the sake of the bottom line.

Thus I would be coding my units as if I was seeing both patients on

an individual basis. Am I being unintentionally fraudulent with the

non-Medicare contractors?

>

> Thanks in advance,

> Hankins, PT/President

> Synergy Therapies, LLC

>

>

>

>