A Step Toward Payment Reform

A Step Toward Payment Reform
New Payment System Evaluation Codes For Physical Therapy A Step Toward Payment Reform How many have wondered about Time Cost You spend the entire 1st visit on the eval and then only one eval code can be reported Other times do a short eval/ session for crutch training for 20 minutes but still use the same eval code There is currently no way to differentiate a simple from a complex case

Coding Reform Wiring & Plumbing for Payment Reform
Coding reform is an initial attempt to move away from the Fee-for-service model of payment to a system that rewards VALUE instead of VOLUME Value, defined as outcomes over cost- where cost of achieving the outcome varies We’ve known that cost varies but we’ve had no system by which to identify high cost cases Coding reform is one incremental step in adapting the infrastructure on the way to payment reform Coding reform is NOT payment reform but one step forward toward payment for an aggregate of services and away from the focus on individual interventions Any future episodic payment will require identification of what we’d expect to be high or low cost patients Lets put this into context: Remember Medicare is clear: the therapy cap would remain in place until there is an alternative payment mechanism So rather than wait for CMS to build the system, APTA took the first step

Payment Reform for Rehab Services
2012 AMA formed PM&R Workgroup (WG) to address changing the reporting methodology consistent with CMS and payment reform efforts AMA PM&R WG continued it’s work focusing on evaluation codes as well as intervention codes to continue to progress from reporting timed procedures to a reporting methodology that describes severity/intensity 2015, February accomplished revision of evaluation codes to be published for 2017 AMA is responsible for CPT code development In 2012, the PM&R workgroup was formed by the AMA. PM&R workgroup is actually composed of 13 provider groups who use the code series CMS has been pushing for payment reform in all areas 2013 to workgroup continued its efforts to shift from reporting “timed” procedures and away from counting minutes to a severity intensity model Move to a value based system incorporating PT clinical decision making based on patient presentation In February 2015 the AMA CPT editorial panel accepted the revised codes New codes to be published in 2017

Payment Reform for Rehab Services
2015 RUC-Eval codes April: surveyed evaluation codes through RUC process. September: presented survey results to RUC for establishment of values to be considered by CMS for 2017 Fee schedule PM&R WG continued work on severity/intensity model for intervention codes. 2016 Interventions on indefinite hold: our path forward will include efforts reflecting input from association members and other stakeholders. APTA is launching an educational campaign designed to help PTs comply with reporting the new evaluation codes Also in 2015, the codes were sent to the RUC or the Relative Value System Update Committee The RUC is responsible for determining the codes RVU’s or values APTA surveyed members throughout the process and presented results to the RUC This year the AMA disbanded the PM&R workgroup Intervention codes were placed on an indefinite hold APTA’s path forward will be informed and reflect efforts by association members and other stakeholders In the meantime. APTA is launching an educational campaign to help PTs comply with the new eval code reporting

CMS PROPOSAL for 2017 All three evaluation codes will be reimbursed at the same level. “…we do not believe that making different payment based on reported complexity for these services is, at current, advantageous for Medicare or Medicare beneficiaries.” (FR* 2016 p. 347) “…stratified payment rates may provide, in some cases, a payment incentive to therapists to upcode…” (FR* 2016 p.345) CMS cannot predict “with a high degree of certainty” the utilization of the different levels of evaluation codes to maintain budget neutrality *Federal Register In July of 2016, CMS released the Proposed Rule indicating all 3 eval codes would be reimbursed at the same level This occurred even though they had been assigned different values by CPT CMS was concerned it could not reasonably predict the use of the different code levels and that costs would go up and it would be unable to maintain budget neutrality APTA and others expressed disagreement and frustration with the decision We await the final rule to be published this month but do not anticipate a change Not clear if other payers will pursue the same course or decide to value the codes differently- payers typically take RVU’s from Medicare and apply their own formula to determine rates CMS plans to collect data on the use of the codes over the next year to determine the target spend and potential payment changes Makes it all the more critical for providers to get this right and code correctly despite the current lack of a payment differential

2017 Evaluation Codes for Physical Therapy
Low Complexity Evaluation Moderate Complexity Evaluation High Complexity Evaluation Re-evaluation A single code Published by the AMA for 2017 Introductory Language Definitions Criteria for Selection Sample cases The 3 new eval codes will replace CPT and the one new re-eval code will replace CPT 97002 The old eval codes will be pulled out of the CPT manual While the codes will be formally pulled, WC and liability carriers are exempt from HIPAA and may chose to continue use the old codes As always, check payer policy OT and AT have new codes that reflect the practice of each profession These new coding systems will not be covered during today’s presentation

Today, in 2016 97001 Physical Therapy Evaluation
Physical Therapy Re-evaluation Published in 1998 and active CPT codes through 2016. This coding structure includes two “service based” codes Do NOT reflect any specific level of complexity or severity Let’s back up little bit and look at the history The PT eval and re-eval codes were published in 1998 and do not reflect current practice As with the new codes, they were untimed These codes are one dimensional …..all evals are considered the same regardless of patient complexity/severity or differing levels of clinical decision making And there were no specific codes to describe eval services performed by a PT

Elements of a Physical Therapy Evaluation
Examination (includes history, systems review, and tests and measures) Evaluation (the thought process leading to identifying impairments, functional limitations, disabilities, and needs for prevention) Diagnosis (impact of the condition on function) Prognosis (professional judgement regarding the predicted functional outcome and the estimated duration of services required) Plan of Care (the culmination of an evaluation) Based on APTA’s Standards of Practice….. Elements of a PT eval include: Examination Medical and functional history Systems review to rule out problems that may or may not be related to the chief complaint and may require consultation with others Tests and measures: used to prove or disprove the hypothesized diagnosis(es) Evaluation – critical thinking and decision making Synthesizing data Guides the diagnosis, prognosis and drives the POC POC – includes coordination, consultation and collaboration of care with physicians and other providers or agencies Synthesis of the eval data guides the diagnosis and prognosis and drives development of the plan of care The evaluation, diagnosis and prognosis constitute the PTs clinical decision making No difference today than it will be in 2017 BUT examination (history, systems review, tests/ measures) and documentation of these findings take on greater significance

Why Are Evaluations So Important?
The evaluation drives the care and/or management of the care A thorough and complete evaluation is critical to success in achieving a positive outcome for the patient’s episode of physical therapy care A reflection of the level of complexity of the patient is key to effective management throughout the episode ALL of the information gathered in the examination drives the POC and determine how the case is managed (amount, frequency, duration, who else should be involved) For payers, key decision making can and should be aligned with the goals of the triple AIM of the ACA- improved access, better care, lower cost A thorough and complete eval will take on even more importance in the future and is critical to achieving a positive outcome for the patient and ultimately for the entire episode of care for the patient’s condition Effective management throughout the episode is founded in sound clinical decision making and is the hallmark of a doctoring profession Differentiates us from technicians- renders PTs decision makers and defines our value- not based on time

Physical Therapy Evaluation
A Physical Therapy Evaluation should clearly reflect: MEDICAL NECESSITY for services to follow Focus on FUNCTION A PT eval should make the case for medical necessity and it is ours to justify Focus on FUNCTION Based on the framework developed under ICF or the International Classification of Functioning, Disability and Health (to be discussed in greater detail later in the presentation) Planned services should be in accordance on the individual patient’s needs and not just the diagnosis

Low Complexity Evaluation Moderate Complexity Evaluation High Complexity Evaluation Re-evaluation* A single code * PT evaluation and PT Re-evaluation will be deleted from the code set. So lets get to the codes Published by the AMA for 2017 and will apply to all PT evals and re-evals occurring on or after January 1st 2017 The old codes will be deleted from the code set for 2017 APTA favored 3 levels of re-eval but AMA disagreed Codes focus on clinical decision making of the PT and patient presentation or complexity Similar to physician E&M codes in terms of stratification BUT different in focus E&M focus on what the physician DOES vs PT codes focus on what the PATIENT looks like

Stratify the patient population Move beyond diagnosis stratification Acknowledge that patients vary due to comorbidities and other personal factors Places value on the clinical decision making required to provide medically necessary care So what these codes do is ….. Stratify patients based on how they present and other factors and MOVE BEYOND diagnosis alone Recognize patients vary based on comorbidities and other factors- therefore, redirect focus to patient needs Places value and greater emphasis on the PT’s clinical decision making

2017 Evaluation Codes for PT Introductory Language:
“…a patient history and an examination with development of a plan of care…which is based on the composite of the patient’s presentation.” “Coordination, consultation and collaboration of care with physicians…consistent with the nature of the problem(s) and the needs of the patient, family, and/or other caregivers.” It is important to note the “Introductory language in CPT”…… IS NO DIFFERENT THAN WHAT OUR STANDARD OF PRACTICE HAS ALWAYS BEEN Patient history and exam with the POC are based on a multi-dimensional composite of the patients presentation Coordination., consultation, and collaboration DO NOT impact level of complexity We are only being asked to do what other healthcare providers do…an expected PT function

Introductory Language: AT A MINIMUM…
Each of the following 4 components noted in the code descriptors must be documented…: History Examination Clinical decision making Development of a plan of care Intro language continued….. AGAIN, THIS IS NO DIFFERENT THAN WHAT OUR STANDARD OF PRACTICE HAS ALWAYS BEEN Need to specifically evidence our clinical decision making

Definitions Body Regions: Head, neck, back, lower extremities, upper extremities, and trunk Body Systems: Musculoskeletal: gross symmetry, gross ROM, gross strength, height and weight Neuromuscular: gross coordinated movement (eg. Balance, gait locomotion, transfers, and transitions) and motor function (motor control and motor learning) Cardiovascular pulmonary: heart rate, respiratory rate, blood pressure, and edema Integumentary: pliability (texture), presence of scar formation, skin color and skin integrity CPT language provides definitions for the purpose of selecting and reporting these codes This is ICF language and it is important to understand and review the listed elements in the body systems

A Review of ANY of the Body Systems ALSO includes:
The assessment of the ability to make needs known Consciousness Orientation (person, place, and time) Expected emotional/behavioral responses Learning preferences (eg learning barriers, education needs) CPT Language: This same language is documented in the CPT book.

Definitions Body Structures: Structural or anatomical parts of body, such as organs, limbs and their components, classified according to body systems CPT also defines body structures…. For example the LE would include: hip, knee, and ankle Joints, muscles, tendons and innervation

Definitions Personal Factors - Factors that include:
Include sex, age, coping styles, social background, education, profession, past/current experience Overall behavior patterns Other factors that influence how disability is experienced by the individual PERSONAL FACTORS THAT EXIST BUT DO NOT IMPACT THE PHYSICAL THERAPY PLAN OF CARE ARE NOT TO BE CONSIDERED WHEN SELECTING A LEVEL OF SERVICE. CPT also provides definitions for: Personal Factors are part of the history and acknowledge differences in the patient beyond diagnosis Consider PFs in the context of the patient’s life- what it means to them Examples of behavior patterns include: fear avoidance, readiness to change, habits etc. Examples of other factors include: cognition, communication skills (need for a translator, inability to make needs known), anxiety, support system, home environment and secondary gain PFs that do NOT impact the PT POC are NOT considered relevant when selecting a level of service IMPACT should be considered in terms of how the PF affects the patient’s response to treatment, POC, and the expected outcome It is critical to clearly DOCUMENT impacts- documentation matters!

International Classification Functioning, Disability, and Health (ICF)
Developed by the World Health Organization (WHO) Standard language and framework for the description of all aspects of health and some health-related components of well-being It is not an etiological framework (such as ICD-10 does) Comes from the perspective of the body, the individual, and society The Concepts and Structure of the PT Evaluation codes ICF is standard language and framework to describe health and is used around the world It is not an etiological framework so is not disease based Comes from the perspective of the body, impact on the individual and the interaction of the individual with society

ICF Information Organization
Functioning and Disability Body systems and body functions Activities and participation (both individual and societal) Contextual Factors Environmental factors Personal factors ICF Organizes Information two ways: Functioning and Disability Body systems and body functions (The person’s body (includes both structure and function) Activities and participation (both individual and societal) Contextual Factors Environmental factors Personal factors You will see a similarity with the framework of these new codes

NEW Codes: 4 Components of Complexity and Severity
Patient history (medical and functional, including relevant comorbidities and personal factors) AND Examination AND the use of standardized tests and measures AND Clinical presentation of the patient AND Clinical decision making (including the use of a standardized patient assessment instrument and/or measurable assessment of functional outcome) WE’VE ALWAYS WONDERED WHY IN THE PAST OUR EVALUATIONS WERE CONSIDERED ONE-SIZE FITS ALL At the same time payers wondered why there is such wide variability in treatment of patients with the same or similar diagnoses So in order to accurately reflect the level of evaluation service….focus is the composite of these 4 components. NOT JUST SIMPLY ON DIAGNOSIS Patient history, examination and clinical presentation take on a new level of importance Standardized tests and measures will help objectify the exam Clinical decision making is YOUR judgement and encompasses multi-dimensional thinking We’ll review each of these components in greater detail

Assists in supporting level of evaluation reported:
Patient History Assists in supporting level of evaluation reported: Comorbidities that impact function and ability to progress through a plan of care Previous functional level; context of current functional abilities Treatment approaches in past if applicable and other factors that may impact patients ability to progress and reach goals Includes social history, living environment, work status, cultural preferences, medications, other clinical tests, and more So let’s look at each component a little more closely Component #1: Patient History both medical and functional Assess comorbidities in terms of their impact on function, the type of services rendered, frequency/ duration of care as well as the patient’s ability to progress through the plan of care Remember, comorbidities are relevant only if they impact the patient’s ability to progress through the POC Examples of comorbidities include: Obesity DM Depression as this is a predictor for development of chronic LBP Cardiovascular ]communication disorders Neuro or ortho conditions Include prior functional level If applicable include treatment approaches by other providers and how they may impact patient progress Also includes social history, living environment, work status, cultural preferences, medications, other clinical tests that might help reveal personal factors

Examination Includes any of the following:
Body structure and functions, Activity limitations (difficulty executing tasks or actions) and/or Participation (in life situations) restrictions Already doing this under Medicare….. These areas are defined by the International Classification of Function (ICF) ICF is our language For the purpose of selecting the right level of eval, the examination criteria allows inclusion of any of the following: (see bullets) Body structure and functions (our traditional impairments such as range, strength, balance., sensation) Activity limitations including executing tasks or actions Participation or restrictions in life situations We will discuss the last two bullets in greater detail on the next slide

ICF Domains of Activity and Participation (includes but are not limited to)
Mobility Self-care Domestic life Interpersonal interactions and relationships Major life areas Community, social and civic life Look familiar? This isn’t new: Functional limitation has been our focus for the purposes of outcomes for a while now. Medicare’s Functional limitation reporting relates to some of these domains as well.

Clinical Presentation of the Patient
Stable and uncomplicated OR Evolving clinical presentation with changing clinical characteristics OR Evolving clinical presentation with unstable and unpredictable characteristics Now we’ll discuss component #3 Dependent on the patient’s report and exam Presentation may be: Stable and unchanging, predictable and uncomplicated OR Evolving w/ changing or inconsistent characteristics (such as LBP that is now radiating into the leg) OR Evolving presentation with unstable and unpredictable characteristics such as orthostatic hypotension that impacts response to activity or treatment Examples include physiological responses: Pain, Blood Pressure Pulse Swelling Sweating Neurological signs Blood sugar

Clinical Judgement and Decision Making
Based on the composite of the patient’s presentation (“the dynamic interaction between the health condition and the contextual factors”- ICF) This clinical judgement occurs at each encounter or session informed as much as possible by current best evidence. Now we’ll discuss component #4…clinical judgement and decision making According to ICF it is “based on the dynamic interaction between the health condition and the contextual factors’- so it is based on a composite of factors As a reminder, clinical judgement occurs at every encounter and not just at the time of the eval and is informed by current best evidence Plus we need to apply the results of standardized patient assessment tools and or functional outcome assessment tools

“Typical Time” is Used as GUIDANCE Only
This time guidance is also published by the AMA Keep in mind the new eval and re-eval codes ate NOT timed codes The times shown are “typical times” only and may not represent the actual time spent with any given patient Not critical component in appropriate code selection Time will NOT be the determinant for the selection of the code….For example, might end up spending a lot of time with a low complexity patient Time was a consideration in the survey process in determining the code values but was NOT a determinant

97161 PT Evaluation- Low Complexity
Here is a snapshot of the code requirements and what they will look like Complexity/severity are determined by the following components: History Examination Presentation of the patient Clinical decision making of the therapist At a minimum, each of the components must be documented in order to report the selected level. Must meet criteria on all 4 categories. If you fall short in any component, default to the lower level of complexity All 3 eval and one re-eval code require these components For Low complexity: History: no PFs or comorbidities affecting the POC Examination: of body systems using standardized tests and measures; Address 1-2 elements in three areas: body structures and functions, activity limitations, participation restrictions Presentation is stable, unchanging and predictable Decision making: focused using standardized patient assessment and functional outcome tools

97162 PT Evaluation- Moderate Complexity
For moderate complexity evaluation: History: w/ 1-2 PFs or comorbidities that affect the POC Exam: of body systems addressing at least 3 elements from body structures/ functions, activity limitations and participation restrictions; At least 3 but the number of tests and measures alone will not determine the level – NOT simply a matter of the number of tests and measures we do Presentation is evolving with changing characteristics Decision making is moderate and encompasses more dimensions

97163 PT Evaluation- High Complexity
High Complexity eval includes: History with 3-4 PFs and or comorbidities Exam using tests and measures to address 4 or more elements from body structures/ functions, activity limitations or participation restrictions Presentation is unstable and unpredictable…..for example, orthostatic hypotension BP unstable either too high or low Pulse too high or low Increasing neurological signs Decision making is more complex due the nature of the exam and presentation MUST hit on all 4 – again if you fall short on any component, default to the lower level of complexity

97164 Physical Therapy Re-evaluation
A single level code Applies when there is an established and ongoing Plan of Care Requires an examination including a review of history AND the use of standardized tests and measures Describes a REVISED plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome There is a single re-evaluation code As with the current re-eval code, it is to be used for established cases and ongoing POC Same elements as on the evaluation levels The exam must include a review of history and use of standardized tests and measures Describes a revised POC using standardized patient assessment instrument and /OR measurable assessment of functional outcome This code should ONLY be reported if the POC is revised APTA resource to assist you in determining when a re-evaluation is appropriate is cited in the references

Building Blocks for New and Emerging Payment Models
Levels of evaluation reflect the complexity of the patient that determines the management path Assessment tools at the front end and outcomes reported at the back end begin to stratify how patients are successfully managed New codes will serve to differentiate the unnecessary variation in care from medically necessary services for the individual patient, and Serve as the building blocks for future payment methodologies Before we get into the patient scenarios, where is this taking us? RATHER than the diagnosis, the level of evaluation will reflect the complexity of the patient and determine the care pathway Reflects the variation of the population within a given diagnosis AND Reflects clinical decision making that is customized for the INDIVIDUAL (no cookie cutter care) Assessment tools at the start of care and outcomes at the back end, help to stratify how patients are successfully managed – what works, what doesn’t drives practice Assessment tools and outcomes necessary to: Collect data See the patterns Develop pathways of care NO COOK BOOK THERAPY!!!! New codes will help to identify unnecessary variations in care from medically necessary services at the individual patient level Coding levels will serve as building blocks for future alternative payment models Remember coding reform is not the same as payment reform but will move us on the continuum to episodic payment BUT we must get this right Accurate code selection and complete and thorough documentation are essential

Patient Scenarios Disclaimer:
Mix of cases- more will be available on the APTA website Scenarios NOT always clear and obvious Documentation is key and these cases will help to demonstrate that fact

Evaluation Code Selection: 97161 □ 97162 □ 97163 □
Patient Case # 1: 41 y/o female with a 3 yr. history of intermittent LBP, increasing in frequency to daily over the past 2 mo. BMI 33, no other co-morbidities; Fluctuating pain from 3-9/10; now 7/10. Ostwestry 35; Work as a day care provider is interrupted at least 1x/wk. due to LBP; Unable to stand more than 5 min; Sleep varies but is impacted 3/5 nights. Start here Evaluation Code Selection: □ □ □

Patient Case # 1: 41 y/o female with a 3 yr
Patient Case # 1: 41 y/o female with a 3 yr. history of intermittent LBP, increasing in frequency to daily over the past 2 mo. BMI 33, no other co-morbidities; Fluctuating pain from 3-9/10; now 7/10. Ostwestry 35; Work as a day care provider is interrupted at least 1x/wk. due to LBP; Unable to stand more than 5 min; Sleep varies but is impacted 3/5 nights. Work Standing Sleep Evolving/Changing Pain BMI Frequency/Chronicity Moderate Ostwestry 35 For history: don’t know prior treatment and or response but high BMI and chronic condition Examination revealed activity limitations and participation restrictions BUT no body, structure or function Does the documentation appear to be complete and thorough? Probably NOT Exam lacks neuro (LE) and trunk range/ stability Presentation: evolving CDM: Even if the exam was more complete (total of 5 (five) w/ neuro/ trunk range & stability) would still be a moderate complexity Evaluation Code Selection: □ □ □

Patient Case # 2: 14 y/o male 4 days post knee sprain playing basketball; no prior injuries; no co-morbidities; Pain is 4/10 (decreased from 8/10 at onset); LEFS score 45; moderate swelling of the knee; limited ROM; moderately impaired balance; no deficits with the trunk, hip or ankle. Evaluation Code Selection: □ □ □

Patient Case # 2: 14 y/o male 4 days post knee sprain playing basketball; no prior injuries; no co-morbidities; Pain is 4/10 (decreased from 8/10 at onset); LEFS score 45; moderate swelling of the knee; limited ROM; moderately impaired balance; no deficits with the trunk, hip or ankle. No relevant co-morbidities or personal factors LE (Knee, hip and ankle) Trunk Stable and predictable Low Complexity  LEFS 45 History: no comorbidities or PFs Examination reveals ONLY body structure and function (organized by body regions) No activity limitations or participation restrictions Presentation: stable CDM: low complexity Evaluation Code Selection: □ □ □

Patient Case # 3: 65 y/o male with 6 month history of pain and stiffness of his right shoulder. Using NSAIDS and is self-limiting activity. History of poorly controlled diabetes; reports dropping objects often, difficulty dressing and other self care activities, and inability to assist in household activities all due to the pain. Shoulder ROM limited in a capsular pattern. Low UEFS score. Evaluation Code Selection: □ □ □

Patient Case # 3: 65 y/o male with 6 month history of pain and stiffness of his right shoulder. Using NSAIDS and is self-limiting activity. History of poorly controlled diabetes; reports dropping objects often, difficulty dressing and other self care activities, and inability to assist in household activities all due to the pain. Shoulder ROM limited in a capsular pattern. Low UEFS score. Carrying/handling Self care Household tasks Upper Extremity Unstable and unpredictable blood sugars Acuity/chronicity Diabetes status Moderate complexity UEFS History: Had there been 3 or more elements … might have been high complexity Exam: Upper extremity- is body structure and function All of these are activity and participation restrictions: carrying/handling Self care Household tasks Presentation is unstable due to blood sugar CDM: Moderate Evaluation Code Selection: □ □ □

Patient Case #4: 32 y/o female reports right posterior pelvic pain (5/10) after stepping off a curb 10 days ago. The pain limits standing on the right lower extremity and transition from sit to stand. Running is limited. Patient is 10 weeks post-partum and delivered vaginally with minimal difficulty. History of intermittent low back pain over the years that typically resolves in 4-5 days. Denies significant past medical issue or need for medication. The PT examined lumbar and hip ROM, joint accessory motion L1-S2 and Sacro-iliac joints, completed SIJ provocation tests and MMT of the hip and trunk.

Patient Case #4: 32 y/o female reports right posterior pelvic pain (5/10) after stepping off a curb 10 days ago. The pain limits standing on the right lower extremity and transition from sit to stand. Running is limited. Patient is 10 weeks post-partum and delivered vaginally with minimal difficulty. History of intermittent low back pain over the years that typically resolves in 4-5 days. Denies significant past medical issue or need for medication. The PT examined lumbar and hip ROM, joint accessory motion L1-S2 and Sacro-iliac joints, completed SIJ provocation tests and MMT of the hip and trunk. Discussion: Typical time is :20 minutes. Medical history w/ no contributing factors aside from prior LBP that resolves on its own Straight forward testing with stable characteristics PF/Comorbidity: 2 Exam had 3 elements all body/ structure/ function that included both hip and trunk measures with passive movement techniques confirming involvement Presentation: change in c/o (evolving) CDM low as focused on pelvic structures and c/o with no other factors from exam or history.

Patient Case #5: 5 y/o girl presents one month s/p percutaneous left heel cord release to facilitate ambulation with heel strike at initial contact. Past medical history is significant for left hemiplegia cerebral palsy. Level 1 - Gross Motor Function Classification System (GMFCS). Prior to surgery, had zero degrees of passive dorsiflexion. Mother reported increasing difficulty with ambulation. Examination: full passive left dorsiflexion; pain with passive stretch to gastroc-soleus muscle. stands independently but does not bear weight on left foot & maintains ankle in plantarflexion. Mother reports she presently crawls rather than walks at home L ankle AROM: dorsiflexion: 6, plantarflexion: 40. Goal of therapy: Independent ambulation without assistive device.

Patient Case #5: 5 y/o girl presents one month s/p percutaneous left heel cord release to facilitate ambulation with heel strike at initial contact. Past medical history is significant for left hemiplegia cerebral palsy. Level 1 - Gross Motor Function Classification System (GMFCS). Prior to surgery, had zero degrees of passive dorsiflexion. Mother reported she was having increasing difficulty w/ ambulation. Examination: full passive left dorsiflexion; pain with passive stretch to gastroc-soleus muscle. stands independently but does not bear weight on left foot & maintains ankle in plantarflexion. Mother reports she presently crawls rather than walks at home L ankle AROM: dorsiflexion: 6, plantarflexion: 40 Goal of therapy is independent ambulation without assistive device. History Examination Presentation Decision-Making L hemiplegic CP GMFCS I PROM L ankle Pain decreased weight bearing L abnormal/reduced mobility Stable, uncomplicated, improving Low complexity History: 2 elements including standardized patient assessment instrument and/or measurable assessment of functional outcome contributed to the selection. Exam: 3 elements including range, pain and weight bearing (body structure function) Presentation: stable CDM: This evaluation defaults to low complexity because the elements for moderate complexity eval were not met. The clinical presentation was stable versus evolving with changing characteristics.

Patient Case #6: 18 y/o female with cystic fibrosis referred to PT for review/ refresh of airway clearance program. She is moving away from home to attend college and needs to be independent in disease management. Patient lives w/ both parents and an older non-CF sibling. Her mother is concerned about her ability to maintain her regimen, including hygiene of respiratory equipment. She has mild airflow obstruction that has been stable for the past few years. No recent hospitalizations. She is not a regular exerciser, but knows better endurance is needed to navigate campus. She has pancreatic insufficiency and takes replacement enzymes. BMI is 19.

Patient Case #6: 18 y/o female with cystic fibrosis is referred to PT for review/refresh of airway clearance program. She is moving away from home to attend college and needs to be independent in disease management. Patient lives w/ both parents and an older non-CF sibling. Her mother is concerned about her ability to maintain her regimen, including hygiene of respiratory equipment. She has mild airflow obstruction that is stable for the past few years. No recent hospitalizations. She is not a regular exerciser, but knows better endurance is needed to navigate campus. She has pancreatic insufficiency and takes replacement enzymes. BMI is 19. History Examination Presentation Decision-Making Imminent decline in psychosocial support Airway Clearance Endurance Stable pulmonary disease & nutritional status Low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome History: one PF Exam: 2 elements body structure function Presentation: stable CDM: low complexity

Patient case #7: 28 y/o male with cystic fibrosis was recently discharged from the hospital following an acute exacerbation with RUL pneumonia. His FEV1% predicted declined to 65% from his typical baseline of 72%. Two exacerbations requiring hospitalization over the past 2 years. Over last year patient lost 12# w/ BMI 18. Past medical history: multiple hospitalizations for pulmonary infections, pancreatic insufficiency, CF-related DM Current Meds: bronchodilators, insulin, pancrease, and mucolytics Social history: married living with spouse. Works FT as a university research librarian Patient goal: Reduce exacerbations and return to life roles in work and family Examination findings include: Course breath sounds throughout; cough strong/ productive of thick, tenacious sputum Mild kyphosis with forward head; decreased rib joint mobility throughout thoracic level SpO2 93% on room air, declines to 90% during 6MWT

Patient case #7: 28 y/o male with cystic fibrosis was recently discharged from the hospital following an acute exacerbation with RUL pneumonia. His FEV1% predicted declined to 65% from his typical baseline of 72%. Two exacerbations requiring hospitalization over the past 2 years. Over last year patient lost 12# w/ BMI 18. Examination: Course breath sounds throughout; cough strong and productive of thick, tenacious sputum Mild kyphosis with forward head; decreased rib joint mobility throughout thoracic level SpO2 93% on room air, declines to 90% during 6MWT History Examination Presentation Decision-Making Current inability to return to FT work Diabetes Airway Clearance Exercise tolerance Posture Thoracic mobility Vital signs Acute decline in pulmonary function Acute decline on nutritional status moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome Past medical history: Current inability to return to FT work Diabetes Exam: 5 systems, body structure functions were assessed Presentation: changing and unstable CDM: moderate complexity Omitted from slide due to space: multiple hospitalizations for pulmonary infections, pancreatic insufficiency, CF-related DM Current Meds: bronchodilators, insulin, pancrease, and mucolytics Social history: married living with spouse. Works FT as a university research librarian Patient goal: Reduce exacerbations and return to life roles in work and family

Patient case #8: 30-month-old female w/ arthrogryposis is 4 wks s/p foot surgery to excise the talus bone bilaterally. Her parents accompany her to the clinic. Bilateral casts were removed a week ago and she is now weight bearing as tolerated. Parents’ goal is for her to walk independently using the posterior rolling walker. Before surgery, she could walk w/ a posterior rolling walker with assistance. She attends daycare and has two older sisters. Examination: Finger flexion contractures bilaterally; both UEs are biased toward extension with hypermobility into excessive extension (0 to 30 deg), limited elbow flexion (0 to 45 deg) LEs fixed into extension w/hypermobility (0 to 20 deg). Ankles are positioned in a neutral Dorsiflexion/Plantarflexion position. Incision sites are closed, clean and dry. Bilateral solid AFOs. Stands w/ minimal assistance with shoes and braces. Walks w/posterior rolling walker for 10 feet before complaints of fatigue & lowering herself to the floor

Patient case #8: 30-month-old female w/ arthrogryposis is 4 wks s/p foot surgery to excise the talus bone bilaterally. Her parents accompany her to the clinic. Bilateral casts were removed a week ago and she is now weight bearing as tolerated. Parents’ goal is for her to walk independently using a posterior rolling walker. Before surgery, she could walk w/ a posterior rolling walker with assistance. She attends daycare and has two older sisters. Examination: Finger flexion contractures bilaterally; both UEs are biased toward extension with hypermobility (0 to 30 deg); limited elbow flexion (0 to 45 deg) LEs fixed into extension w/ hypermobility (0 to 20 deg). Ankles are positioned in neutral Dorsiflexion/ Plantarflexion position. Incision sites are closed, clean and dry. Bilateral solid AFOs. Stands w/ minimal assistance with shoes and braces. Walks w/posterior rolling walker for 10 feet before complaints of fatigue & lowering herself to the floor ic reassessment, trial for modification,or change in assistive device History Examination Presentation Decision-Making 30 month old with arthrogryposis 4 weeks post reconstructive surgery bilateral feet Multi-joint involvement Pain decreased weight bearing Abnormal/reduced mobility fatigue Unstable characteristics at risk for decline in mobility High complexity History: 3 PFs and comorbidities Exam: 2 body, structure, function and 2 activity limitation/ participation restriction Presentation: unstable CDM: high complexity

Where can you learn more about these new codes?
Coming before the end of the year: Online self-paced course w/ examples of scenarios from various patient populations will be available in the Learning Center at APTA pocket guide (12/2016 PTinMotion) FAQ from 9/2016 webinar FAQ from September webinar

Where can you learn more about these new codes?
Published articles in PTinMotion magazine The following references….

References

References APTA Guide to Physical Therapist Practice 3.0; APTA Guideline: Physical Therapy Documentation of Patient/Client Management; BOD G 2017 CPT® Manual, Professional Edition APTA FAQ: Evaluation & Reevaluation International Classification of Functioning, Disability and Health (ICF), WHO 2001

Final 2017 Physician Fee Schedule
CMS held to the tiered evaluation codes – and the same reimbursement for each. CMS reconsidered and will increase payment for reevaluation from 0.60 to 0.75. Claim reviewers won't be able to use the new codes to "ding" manual medical reviews. The misvalued codes—all 10 of them—will be in play in 2018. APTA regulatory affairs staff is reviewing the final rule and will develop a more detailed summary in the coming weeks. The rule covers Medicare Part B services that apply to physical therapists (PTs), physicians, and other providers. ##APTA will issue a more detailed summary in the of the coming weeks. Here are a few highlights: CMS held to the tiered evaluation codes – and the same reimbursement for each. CMS adopted much of the system created by the American Medical Association (AMA) CPT Editorial Panel to retool current procedural terminology (CPT) codes for physical therapy evaluation and reevaluation. The new evaluation code descriptors stratify evaluations by complexity—low (97161), moderate (97162), and high (97163)—but CMS will keep the longstanding relative value unit (RVU) of 1.20 for all 3 levels of evaluation. That decision, opposed by APTA, is a departure from recommendations from the AMA Relative Value Scale Update Committee. These codes replace the existing and codes, which will expire on January 1, 2017, when the new codes are implemented. CMS reconsidered and will increase payment for reevaluation. The rule also includes 1 new reevaluation code (97164). In the proposed rule, this code carried a reevaluation rate of .60, same as for the old reevaluation code. In the final rule, that rate was increased to 0.75. Claim reviewers won't be able to use the new codes to "ding" manual medical reviews. In an acknowledgment of APTA's concerns for adequate time to educate PTs on the use of the new coding system, CMS decided that no changes will be made to the Medicare benefits policy manual for 2017—that means reviewers won't be able to penalize providers regarding the medical necessity for the new evaluation requirements. This “grace period” won't last, however, which puts pressure on the profession to use the reprieve to work toward consistent, accurate coding. The therapy cap gets a $20 increase. The Medicare therapy cap will be $1980, up from the 2016 cap of $1960 (the therapy cap exceptions process extends through December 31, 2017, under MACRA). The misvalued codes—all 10 of them—will be in play in In the 2016 physician fee schedule, CMS identified multiple potentially misvalued codes, including some commonly used in physical therapy, for review and potential revaluation. CMS has confirmed that all 10 physical therapy-related CPT codes that it identified as potentially misvalued will be revalued in the 2018 fee schedule. A random sample of APTA members recently received a survey on these and other codes, and APTA is urging them to complete the questionnaire to help ensure accurate valuation. The conversion factor is up—a little. The 2017 Medicare conversion factor is $35.88, slightly higher than last year's conversion factor of $35.83.

APTA Opioid Campaign

Q3 Highlights June launch at NEXT Times Square billboard
Online advertising Strong chapter support Online/social release of video PSA

Q4 Highlights NY student appearances on TODAY and GMA morning shows
PSAs (TV and radio) airing nationwide Online/social advertising continues Multiple component campaigns

Pain Question: How much did we spend on treating pain in 2010?
Answer: $500 –$635 billion dollars Compared to… $150 billion dollars in 1995 Spending on pain increased 4x in 15 years Gaskin DJ, Richard P. The Economic Costs of Pain in the United States. The Journal of Pain, 2012; 13 (8).

Is this money well spent?
One management strategy that rapidly drove up costs was rate of prescription opioids Sales of prescription opioids have literally quadrupled since 1999 So have opioid related deaths (165,000 since 1999) 1/5 patients who present to a physicians office w/ complaint of pain, will be prescribed an opioid One pain management strategy: opioids Sales of prescription opioids gone up 4x since 1999 Opioid deaths also on the rise 20% of patients reporting to an MD office with c/o pain are prescribed an opioid

Feeding Our Nation Opioids
In 2012, 259 million prescriptions for opioid pain medication written. To put this into perspective: There 300 million people living in the United States

Where’s the Evidence? The CDC says…
Insufficient evidence to support long-term opioid use and little evidence that they improve functional outcomes If opioids are used, they should be combined with non-pharmacological therapy, such as physical therapy “Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh the risks to the patient.”

Where’s the Evidence? “High-quality evidence” (CDC) that exercise as part of a physical therapy treatment plan for low back pain, hip and knee osteoarthritis, and fibromyalgia is effective for reducing pain and improving function. We need to move toward better pain management…

Know Pain, Know Gain “Knowing Pain” (neurophysiological explanation from a PT) reduces overall cost of care Overutilization of Imaging increases costs (and fear) Early activity and movement decreases long-term costs

Knowing Pain A recent study published in the journal Spine (2014), followed a group of individuals who were undergoing surgery of the lumbar spine. The researchers followed up with the participants 1 year after surgery and found the group who received a single, educational session from a physical therapist, viewed their surgical experience much more favorably, and utilized 45% less health care expenditure following surgery. Louw A, Diener I, Landers MR, et al. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine 2014: 39;

Image Overutilization
Researchers have found that individuals who get advanced imaging for LBP will cost $4700 more as compared to those who get PT first “Labeling” (Fritz et al 2015)

Early Activity and Movement
Early PT for pain decreases risk for advanced imaging, additional physician visits, surgery, injections and opioids (Fritz 2012) Total medical costs are $2736 lower

Early Activity and Movement
Physical therapy is a safe and effective solution for long-term pain management Early physical therapy is cost-effective relative to usual primary care after 1 year for patients with non-specific LBP (Fritz 2016)

Registry

Data Collection Practice Payment Quality Research
Organized data collection system that allows therapists to evaluate patient function (& other measures) for PT patients Typically designed primarily for research or quality improvement Research – focused on a question, usually has an expiration – While research potential is a byproduct of PTOR data collection…. Quality – Focused on measuring outcomes and enabling providers to perform quality improvement initiatives This is where policy and healthcare reform have landed More emphasis on pay-for-performance Increasing transparency and accountability Explain variation in care Will show how PT can change lives* Help clinicians deliver even better outcomes (hard to improve when you don’t know what needs improvement) Who develops registries? Associations Empowerment: those who represent the profession set the standard Why PTOR stands out (in growing registry space) 1st – Many medical registries have narrow focus (device, condition, patient population) Continuum of care – across settings, lifespan, all conditions, all patient populations (ambitious!) 2nd – Uniquely match patients over time 3rd – Potential scale ©2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.

Physical Therapy Outcomes Registry
Track performance of care delivery and documentation patterns Assess adherence to CPGs Fulfill quality reporting requirements Support quality improvement initiatives Practice Quality Drive health services research initiatives Demonstrate value of physical therapist services Research Payment Inform payment contract negotiations Guide payment policy Wide-ranging benefits to PTs being measured in a more meaningful way: Payment: could use data to support/advocate for payment policy, PTs could leverage data in contract negotiations Payment/Research: Help explain the variance in care Research: Longitudinal data, big potential for robust health service research initiatives Quality: Main goal of registry is enabling clinicians to undertake quality improvement initiatives, helps PTs more successfully report on PQRS measures (and with QCDR create more meaningful measures) Practice: Patterns in care, eventually develop predictive analytics to be able to influence clinical decision-making

Data From the Profession For the Profession
When you use a PT Outcomes Registry, you help to ensure that physical therapists, rather than other parties, identify what practices work best and for whom.

How PT Outcomes Registry Works
Inputs Demographic information, Diagnosis/ condition (via ICD-10) Comorbidities (via ICD-10) Relevant surgical history (planned) Pain intensity Functional level (global, condition/ body region specific, performance based) CPT codes Outputs Reports allows clinicians to look at individual episode and aggregated episodes by diagnosis/ condition Change in function over the episode and functional level achieved Change in pain over the episode Number of visits per episode Quality performance ©2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.

Practices can use PT Outcomes Registry data to:

Registry Timeline Sum up, next steps:
Pilot phase 2015 2016 Summer Close Pilot Soft Launch 2016 Fall 2017 Public Launch Sum up, next steps: 2015/ 2016 – Pilot year, establishment of SAP, system tweaks, prep for public launch Late 2016 – Soft launch 2017 – Public Launch 2017 – QCDR & quality measures, addition of modules, continued EHR partnership growth, growing database Since piloting, consider this a teaser  will have a more robust database as time goes on In the meantime can focus on strategically sound partnership development As registry becomes more established, keeping one eye on today, another on tomorrow Looking at value is an ongoing continuous process What we know today may change, may evolve as new models of care are developed ©2016 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.

can help you visually show the status of your practice.
PT Outcomes Registry can help you visually show the status of your practice. For more information :

Manual Therapy

Manual Therapy CPT Code 97140
Skilled interventions to joints/ soft tissue Improve tissue extensibility; increase range of motion; mobilize or manipulate soft tissue and joints; modulate pain; reduce soft tissue swelling, inflammation, or restriction May include manual lymphatic drainage, manual traction, massage, mobilization/manipulation, and passive range of motion. Manual therapy techniques are skilled interventions applied by physical therapists to joints and soft tissue and “are intended to improve tissue extensibility; increase range of motion; mobilize or manipulate soft tissue and joints; modulate pain; reduce soft tissue swelling, 2 inflammation, or restriction.”1 Manual therapy techniques may include manual lymphatic drainage, manual traction, massage, mobilization/manipulation, and passive range of motion.

Literature reviews highlight efficacy of manual therapy AND cost benefits on the total episode of care One study focused on cost-effectiveness of MT techniques vs corticosteroid injection for chronic lateral epicondylalgia Study result: patients receiving PT had higher initial costs but overall cost of care was lower than w/ corticosteroid injections Academic studies and literature reviews help highlight not only the efficacy of manual therapy but the cost benefits on the total episode of care. For example, one study focused on the cost-effectiveness of physical therapy, and specifically the use of manual therapy techniques, compared with corticosteroid injection for chronic lateral epicondylalgia. The study found that patients receiving physical therapy had higher initial costs; however, when the long-term patient cost of care was examined, physical therapy was shown to be more cost effective than corticosteroid injections.

Since 2015 increased code scrutiny by a few commercial payers Mid west payer proposed 35% reduction for this procedure State of Virginia employees (covered by one commercial payer) have separate MT co pay if used during treatment session Health Care Service Corporation: Blue Cross Blue Shield of Illinois (BCBSIL) in 2015 attempted to reduce MT payment by 35% State of Virginia employees covered by one of the commercial payers has an ongoing issue with manual therapy being classified under a separate benefit than their physical therapy benefit which translates to dual co pay requirement when the CPT code is submitted

APTA efforts: Met w/ affected states in the mid west & payer to discuss effectiveness of manual therapy Sent letter including research evidence illustrating MT benefit Results: Payer agreed to modify proposed reduction

State of Virginia Efforts to resolve: Chapter leading effort to interface w/ payer & developer of state employees benefit

Major commercial payer Louisiana: Separate co pay when MT is used during a treatment session and Will deny payment if MT is billed & practitioner IS NOT a chiro Florida auto liability carrier is denying payment when CPT is submitted on claims Louisiana BCBS plans have dual co pay for MT and traditional therapy and DENIALS if is billed if the practitioner IS NOT A chiropractor

State of Florida and Louisiana Efforts to resolve: APTA monitoring chapter efforts/ providing resources as needed APTA Plans: To create a defense paper that will be available for chapters to use

A Step Toward Payment Reform

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