Re: Observations from a Utilization Reviewer

[Guest guest]

Alan,

Thank you for sharing your thoughts. I have done a small amuont of Utilization

Review in the past and own my own outpaitent PT clinic. Although, at my office,

I feel we do a pretty good job with most of the items you mentioned, it is great

to have reminders like this to refocus and make sure that we are doing an even

better job of documenting our level of expertise and care.

The PT diagnosis is a great opportunity to share with the patient and the rest

of the healthcare practitioners our ability to truly figure out what is wrong

with them. Unfortunately, it seems way too many PTs focus on the symptoms and

do not even really try to uncover the source of the s/s. It does take time and

effort to do this correctly and involves more than just the one body part.

I really encourage all PTs to take the time to do this and you will find that

you really can make a difference in getting your patients better quicker and

with much better final results. You will also probably prevent other issues by

correcting the source versus just calming down the acute symptoms.

I know many PTs (probably more likely ones that are not on this list-serv)will

say that they do not have time to really do this. I agree that if you are

trying to treat multiple patients at once, then you probably do not have the

time. If that is the case, then change jobs or refuse to treat multiple

patients at once. We should be giving the patients the time that they need (and

billing appropriately for it).

Thanks again for your post.

Brad Freemyer, PT

Roswell, GA

>

>

> Subject: Observation from a Utilization Reviewer

> To: hpa-list

> Date: Sunday, October 9, 2011, 7:29 PM

>

> All,

> I recently reviewed several hundreds of initial evals & POCs from PT providers

in three states.  For your consideration, these are the

> unfortunate trends that I see in way too many cases.  Doesn't matter if it is

a BS, MPT, or DPT.  Doesn't change with setting or years of experience.   

[Guest guest]

Alan, thanks for your insights. I agree with everything you brought up except

with your explanation of what a PT diagnosis is. This is a hearty topic and one

that is decades in discussion (see Rose, PTJ, 1989; Jette, PTJ, 1989). While

your example is correct in identifying that " decreased strength, decreased ROM,

increased pain " is a list of S/S and not a PT diagnosis, your suggestion,

however, to refine the " R shoulder pain " initial script diagnosis to

" subscapularis strain with bicipital tendinitis " still falls within the realm of

a medical, pathoanatomic diagnosis and not a true PT diagnosis. Sahrmann has

described PT diagnosis this way (PTJ, 1988):

Diagnosis is the term that names the primary dysfunction toward which the

physical therapist directs treatment.

PT diagnoses should fundamentally identify dysfunctions of the movement system,

cardiorespiratory system, integumentary system, etc. and not " step on toes " by

refining the original medical diagnosis. Using your example, perhaps a clearer

PT diagnosis might read, " impaired scapulohumeral dynamic stability leading to

impingement pattern " . This gives the clinician a clearer path to follow with

their interventions and justifies the need for skilled therapy. A differential

diagnosis process will certainly refine the understanding of what specifically

is contributing to the symptoms, but these pathoanatomic assessments should be

outlined in the Assessment/Clinical Impression section rather than the PT

Diagnosis. Perhaps one approach to help with some of the confusion may be to

list the medical diagnosis and then the PT diagnosis in close proximity on every

note to more clearly indicate there are two different scopes of practice being

applied.

Over the years we have seen several systems attempt to provide a more unified

lexicon for PT diagnosis--Sahrmann's Movement Impairment Syndromes, Delitto's

Treatment-based Classification System, APTA's Guide to PT Practice, etc.--and

what you are probably seeing is first-hand evidence of the confusion within our

profession. In my specialty of orthopedics and manual therapy this language

barrier has been aptly termed " gibberish " (Flynn, et al., 2008). If we are to

help distinguish our profession's value from the slew of other technicians and

professionals out there doing similar work (as Sahrmann helped accomplish in the

1960's!), we must have an agreed-upon, cohesive, and universally-applied

terminology and understood role for PT diagnosis. And right now, we just don't

have it.

B Schroedter, PT, DPT

Movement Thru Rehab

Miami Beach, FL

>

>

> Subject: Observation from a Utilization Reviewer

> To: hpa-list

> Date: Sunday, October 9, 2011, 7:29 PM

>

> All,

> I recently reviewed several hundreds of initial evals & POCs from PT providers

in three states.  For your consideration, these are the

> unfortunate trends that I see in way too many cases.  Doesn't matter if it is

a BS, MPT, or DPT.  Doesn't change with setting or years of experience.   

> I hope this generates discussion and is meant to bolster our profession

through quality improvement.  Nationwide, third party payors are looking with

more scrutiny and this will only get more meticulous.

> Better to hear it from a PT in the profession than someone else.

>

> My observations in no particular order:

> Superficial exams.  If the patient comes in with neuro radicular complaints,

why don't I see a neuro based

> exam?  No DTRs, dermatomal/myotomal screening, etc.  Infrequently they will

comment on absence of b/b changes.  

> Too many blank spaces.  If you didn't evaluate it, then acknowledge this with

a NT or NA.  When you leave huge blank spaces through the PT evaluation form you

look lazy.

> PT diagnosis.  Why do therapists list an accumulation of symptoms instead of a

true PT diagnosis?  I see " decreased strength, decreased ROM, increased pain. "

 This is not a PT diagnosis and doesn't permit our profession to demonstrate our

skill with differential diagnosis which can often be more refined than the MD

diagnosis for " R shoulder pain. "  I would love to see more PT's discern that it

is a subscapularis strain with bicipital tendinitis...

> Limited manual therapy.  We are physical therapists.  Physical.  Hands-on is

our forte.

>  What is the love affair with piling on the modalities

> and having them do supervised therex?  Please add manual therapy when

appropriate.  It tells me that you are not too busy to care for my patient.

> Failing to keep abreast with the evidence based literature.  Chronic pain x 30

years probably won't respond to MH, TENS, interferrential, biofreeze,

phonophoresis, etc.  We need to be honest with ourselves and our patients and

know our limitations.  

> Why do I see requests for 30 visits on an initial eval?  Nothing that far into

the future is predictable.  I question your judgment when you do this.  

> When therapists request 2-3 visits per week x 4-6 weeks (8-18 visits), they

are signaling that they feel capable of achieving goals within 8 visits.  

> Is every diagnosis 2-3 x 4-6?  I see this 99% of the time.  When you vary the

frequency and duration from case

> to case it indicates that you have considered the patient's

> availability and adjusted your requested visits based upon the diagnosis.

 Sort of like 'Name that Tune'... " I can treat this diagnosis in 6 visits. "  You

have more credibility than the 2-3 x 4-6 therapist and I may look favorably on

future authorizations.

> Absence of objective measurement tools.  I rarely see the Oswestry, DASH, and

the others you can name.  And when they are used, it often doesn't become tied

to a goal.

> Use age matched cohort ROM considerations.  Don't list a goal for 180 degrees

shoulder flexion for a 89 year old farmer and then request more visits because

you're only at 175.

> Limited evidence of healthy education teaching.  I wish I saw more

documentation and goals that spoke to education re: energy conservation, symptom

self-management, avoidance of aggravating factors, joint conservation, caregiver

education, offering the patient

> information on community support groups for their

> chronic diagnosis, etc.  We seem to be stuck on resolving the immediate

problem and haven't yet ventured into connecting the dots with healthy living

and other support systems post therapy d/c.

> Irritation with the authorization reviewers.  When we call for more

information on a case we are paying you for, provide the information we seek

without a chip on your shoulder.  It is unbecoming.

> Daily notes are blah.  Cut and paste from the previous day just updating the

3# to #3.5.  An assessment is an assessment and shouldn't be " tolerated session

well. "  A parakeet can ascertain this.  Give me a bona fide assessment or don't

write anything.

> Similarly, when I don't see skilled therapy progression from session to

session I begin to wonder if you are squandering visits.  And chances are often

that you are.  You should've been able to reach the

> goals within 12 visits but you are on 19 and want

> 12 more.  I will remember you.

> Respectfully,

>

> Alan Petrazzi, MPT, MPMPittsburgh, PA

>

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