RE: Physician referrals -- follow to the letter?

January 6, 2011

Leigh,

I am not sure what the official right answer would be but...

I have seen this handled several ways:

1) Some PTs write POC with only what they plan to do and when the Dr. signs it,

then they are covered.

2) Some do US for instance once or twice so they can say they at least tried

what the Dr. said and then do whatever they think is indicated.Â

3) Some call Dr or nurse and recommend what they think is best. (most Docs OK

that)

3) What helped me was to print up script pads that had a check box for eval and

treat, with a small section to put anything specific they wanted to include or

exclude. With a little bit of education all the doctors I worked with learned to

just check the eval and treat box .

Greg

________________________________

To: PTManager

Sent: Thu, January 6, 2011 12:21:58 PM

Subject: Physician referrals -- follow to the letter?

Â

When a referral for PT comes from a physician that includes modalities that the

therapist chooses not to use, is there any requirement (state law, Joint

Commission, CMS, or other) that this be addressed in the documentation or with

involvement of the physician?

For example, a prescription for PT treatment of chondromalacia patella specifies

ultrasound and VMO strengthening, and the therapist instead does ankle

mobilization, patellar taping and glute strengthening based on his examination

findings and assessment. Must the MD agree, or can the PT proceed as he sees

fit, reporting the results to the physician in a progress note? (This is in a

hospital-based outpatient setting.)

Thanks for your input.

Leigh , MSPT

San Francisco, CA

January 7, 2011

Some payers will require a POC and this is often matched to the therapy that is

ultimately reimbursed, so in a broad sense it is best they match. The easiest

way to handle this is to communicate with the referral sources that PT is a

service that can determine the best course of treatment by ordering EVALUATION

and TREATMENT .

This is another issue in itself , but we must continue to educate the public and

the referral sources that PT is not an ordered " product " like a lab or x-ray

but rather a professional service capable of making autonomous medical

decisions and treatment plans

Another option is to create a POC document that acknowledges the order but lines

out the actual plan , frequency and goals of the treatment plan ( based on

evaluation findings) - seek physician approval by adding signature line

Ron Barbato PT

Administrative Director, Rehabilitation Services

Program Director, Cancer Support Services

Ephraim McDowell Health

rbarbato@...

PRIVILEGED AND CONFIDENTIAL: This transmission may contain information that is

privileged subject to attorney-client privilege or attorney work product,

confidential and/or exempt from disclosure under applicable law. If you are not

the intended recipient, then please do not read it and be aware that any

disclosure, copying, distribution, or use of the information contained herein

(including any reliance thereon) is STRICTLY PROHIBITED. If you received this

transmission in error, please immediately advise me, by reply e-mail, and delete

this message and any attachments without retaining a copy in any form. Thank

you.

Physician referrals -- follow to the letter?

When a referral for PT comes from a physician that includes modalities that the

therapist chooses not to use, is there any requirement (state law, Joint

Commission, CMS, or other) that this be addressed in the documentation or with

involvement of the physician?

For example, a prescription for PT treatment of chondromalacia patella specifies

ultrasound and VMO strengthening, and the therapist instead does ankle

mobilization, patellar taping and glute strengthening based on his examination

findings and assessment. Must the MD agree, or can the PT proceed as he sees

fit, reporting the results to the physician in a progress note? (This is in a

hospital-based outpatient setting.)

Thanks for your input.

Leigh , MSPT

San Francisco, CA

January 7, 2011

..Hi Leigh,

I will address Medicare specifically:

Medicare Part B does not require a physician referral. It does require

certification and an approved treatment plan. So it does not matter what

is on the prescription, only what is on the treatment plan.

This can be handled a couple of ways. If the physician is usually adament

about what treatment to use and changes are suggested, then it probably

would be wise to contact the physician to clarify the plan. Or simply,

you can simply fill out the new treatment on the plan and send it to the

physician for approval.

Once you get the certification and signed treatment plan back from the

physician, Medicare is very specific about further changes in the plan.

Any major changes such as the ones you mention, will necessitate sending

the treatment plan back to the physician for approval.

Now a word about non-Medicare clients: if not being done, a possible

helpful solution is, after the evaluation is complete, send a written

treatment plan back to the physician for every client.

This allows for communication of changes recommended which can then be

approved or rejecdted by the physician. Once trust is established, most

physicians will willingly allow chnages and as has been our experience,

will write an " eval and treat " referral and allow us to determine the

appropriate treatment which they can then approve when we send them the

treatment plan.

> Leigh,

> I am not sure what the official right answer would be but...

> I have seen this handled several ways:

> 1) Some PTs write POC with only what they plan to do and when the Dr.

> signs it, then they are covered.

> 2) Some do US for instance once or twice so they can say they at least

> tried what the Dr. said and then do whatever they think is indicated.Â

> 3) Some call Dr or nurse and recommend what they think is best. (most

> Docs OK that)

> 3) What helped me was to print up script pads that had a check box for

> eval and treat, with a small section to put anything specific they

> wanted to include or exclude. With a little bit of education all the

> doctors I worked with learned to just check the eval and treat box .

> Greg

>

> ________________________________

>

> To: PTManager

> Sent: Thu, January 6, 2011 12:21:58 PM

> Subject: Physician referrals -- follow to the letter?

>

> Â

> When a referral for PT comes from a physician that includes modalities

> that the therapist chooses not to use, is there any requirement (state

> law, Joint Commission, CMS, or other) that this be addressed in the

> documentation or with involvement of the physician?

>

> For example, a prescription for PT treatment of chondromalacia patella

> specifies ultrasound and VMO strengthening, and the therapist instead

> does ankle mobilization, patellar taping and glute strengthening based

> on his examination findings and assessment. Must the MD agree, or can

> the PT proceed as he sees fit, reporting the results to the physician

> in a progress note? (This is in a hospital-based outpatient setting.)

>

> Thanks for your input.

>

> Leigh , MSPT

> San Francisco, CA

>

January 7, 2011

I do not believe that a referral is a prescription, or is a set of

directions. When my family practitioner refers me to an orthopedist,

podiatrist, or pulmonologist, it is not with directions or a protocol, else

he is treating the pulmonologist, et. al. as a technician. Right?

Just to keep us in touch with our own core principles, from The Code of

Ethics, here's Principle # 3:

Principle #3: Physical therapists shall be accountable for making sound

professional judgments.

3A. Physical therapists shall demonstrate independent and objective

professional judgment in the patient's/client's best interest in all

practice settings.

3B. Physical therapists shall demonstrate professional judgment informed by

professional standards, evidence (including current literature and

established best practice), practitioner experience, and patient/client

values.

3C. Physical therapists shall make judgments within their scope of practice

and level of expertise and shall communicate with, collaborate with, or

refer to peers or other health care professionals when necessary.

3D. Physical therapists shall not engage in conflicts of interest that

interfere with professional judgment.

3E. Physical therapists shall provide appropriate direction of and

communication with physical therapist assistants and support

personnel.

Dick Hillyer, PT,DPT,MBA,MSM

_____