Defining "Skilled care" (Full Version)

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TexasOrtho -> Defining "Skilled care" (January 1, 2008 8:53:30 PM)

Hey folks.  I've got one that's been on my mind lately.  There seems to be some variability in how each of us may view the term "skilled care" as it pertains to our daily practice.  I am curious how you might define or describe it as it pertains to your practice patterns.

I don't have a precise definition at this point as it pertains to me, but I may have a few examples.  An obvious example: I believe joint mobilizations are skilled care.  Everything from the decision to utilize them all the way to assessing the outcome fits my definition of skilled care. 

A more complicated one, in my opinion, is for therapeutic exercise when a portion of the activity is "skilled care" while the remaining portion could be considered autonomous activity of the patient.  Is it truly skilled from the moment the patient begins using the ergometer all the way through the 10 minutes of activity?  Or is the skilled portion when you determined the necessary dosage of activity?  Other exercises such as leg raises, bridges, and others could present the same issue.

My personal view is that the skilled portion of some activities represents a smaller percentage of the interaction that what we may believe.  Why do I think this is important?  Look what has happened to passive modalities such as hot and cold packs.  The choice to utilize them is based on our understanding of the pathology as it relates to our patient.  However, based on many payors, they are autonomous modalities the patient can perform on their own.  As such they are no longer reimbursed for many payors.

This may be no more than a mental exercise, but I think it has implications for things ranging from billing to utilization of technicians in the clinic.  An interesting parallel occurs at your local primary care physician's office.  You are often initially seen by either a nurse (PTA) or medical assistant (tech) for things like blood pressure or even elements of the history.  The physician then follows up with the key decision making aspects of your case.  The entire event is billed as skilled care. 

If the "tip of the spear" providers can effectively utilize this practice, is it not appropriate for us to be able to do the same without feeling we've cheated our patients?  I can certainly see both sides to this issue, but would like to hear if anyone has thought about this in the past.  Any input would be appreciated.

Happy New Year!



pdtoal -> RE: Defining "Skilled care" (January 5, 2008 2:08:35 PM)

I've discussed this with a classmate previously.  At his clinic, they do not bill more than 1-2 min of Bike, UBE, etc, b/c they believe after the first couple of minutes it stops being "skilled care."  In our clinic we do bill for that entire time because the decision to utilize that exercise was skilled and we do alter settings as necessary.  I, also, see both sides of the arguement and would be very interested to hear how others around the country bill Medicare patients when using Bike, UBE, etc. 



Kaden -> RE: Defining "Skilled care" (January 5, 2008 4:56:35 PM)

I bill for the time it took to set up on the bike and any time I may have gone back to asses how they were doing.  The rest of the time is a patient pedaling and is not skilled care.

I am not sure about MC's take on this but I know they are clear when it comes to direct contact units.  If you are seeing another patient at the same time then you cannot be billing for the entire duration of the bike, UBE, etc.



TexasOrtho -> RE: Defining "Skilled care" (January 5, 2008 5:40:54 PM)

The medicare guidelines are indeed clear (albeit overburdensome) on the direct contact issue.  My question is how it pertains to our skill.  Again, I go back to the primary care provider example.  Let's say the medical assistant, a certificate-level provider, takes a patients blood pressure and notes a significant change in status.  This, in turn, causes a major change in the physician's assessment and management of the patient's hypertension.  Does this make the fact an MA took the blood pressure any less of a skilled episode of care for the patient? 

Ideally, you'd like the physician to take your blood pressure and give your his/her interpretation on the spot.  The reality is this never (or very rarely) happens.  Nonetheless, the resultant treatment is no less effective and does not affect the clinical outcome.

I understand the need for medicare to control costs, but I feel like we are getting pushed around way too much on issues like this.  Furthermore, I believe it sets up dangerous precedents for the future of our businesses.  I would support an APTA initiative to get CMS to reconsider the direct contact guidelines currently imposed on us.  I don't think techs and support staff should overstep their boundaries, but using them in an efficient manner can support the care of each patient.  It is a model that works very well in many physician offices.  If we are to one day achieve autonomous practice, these are issues which will need to be addressed. 



Kaden -> RE: Defining "Skilled care" (January 5, 2008 6:47:50 PM)

Rod,

Well said, I agree with everything stated in your post.  My first reply was simply stating how I bill not that I agree with PT's being held hostage by direct contact  rules.

The only problem I see with giving more freedom to techs and assistants is that for every PT such as yourself who will do so responsibly there are others out there who will bend to rules soley for financial gain, rather than looking at the new found freedom as a way to provide more efficient care.

Back in the mid 80's PT's had this kind of freedom where a tech could have more of a direct role.  The problem is so many of them abused this, such as having a tech oversee 6 patients in the gym and billing for it that MC changed guidelines.

It does seem unfair that MC guidelines seem to financially handicap those of us trying to provide quality, efficient care.  As PT's we can help this by refusing to work in situations where the rules are constantly bent to improve financial gain.  We all know clinics out there like this and unfortuneatly it creates a viscious circle of more regulations being imposed on those practicing within the rules.



TexasOrtho -> RE: Defining "Skilled care" (January 5, 2008 7:18:07 PM)

Agreed.  I currently work in a single PT clinic (just me) in a small rural community.  This clinic is not raking in crazy money like some of the mega huge clinics out there.  In order to get patients seen, I need techs to see a modest volume of patients 12-15 per day.  This allows me to keep up with patient care, administrative duties, documentation etc.  If it weren't for my technician, I'd be working 60-80 hour weeks to keep my clinic barely in the black. 

It seems like we were just handed this direct contact rule and rolled over.  I also agree that the PT clinics of the 80's got fat off abusing the priviledge of using support staff.  I just wish there could be a happy medium.  Can you imagine how strongly the AMA would react if CMS said they would no longer reimburse them for services rendered by nurses or MA's?  I don't expect us to have the same leverage as the AMA, but a decent level of legistlative respect would be nice. 

Like you Kaden, I sometimes worry about the future of our profession.  Issues like this are going to really affect our practice if we continue to allow it to happen.  I'd like to see us go on the offensive and be ready to play hardball for the profession.  If that means punching some folks in the mouth (figuratively of course) to get there, I am all for it.  Otherwise, our profession is going to lose some very good members.



SJBird55 -> RE: Defining "Skilled care" (January 5, 2008 7:24:23 PM)

The argument that can be used with "direct" care," in particular with Medicare B in the private practice setting is simple.  With Medicare A, specifically home health, physical therapist assistants can provide care independently with the supervising physical therapist available via phone.

I, personally, do not support the use of physical therapist assistants with my patient population.  There is too much crap being reassessed and decisions being made sooner than 2 weeks or 6 visits AND higher copays/deductibles WITH a decreased frequency of visits.  Granted, if and only if one PTA was teamed with one PT, I could see that being a feasible approach where both providers would know each other and be able to provide a consistent message.  With that type of situation the patient could be seen by both the PT and the PTA depending on the needs of the patient and that kind of a structure could work.  Typically what really occurs though is the patient can only come at 3 pm and PTA X has an opening on that day... but then on the next appointment PTA Y is the one available and so it goes.  No consistency of care and varying messages sent to the patient depending on the educational level or belief of the provider.  What happens is not a patient centered approach.

With the suggestion you are making, Rod... obviously the nurse is screening or collecting data - the physician pieces everything together.  A PA and a FNP seem to function quite a bit more independently.  When I was working quite closely with a family practice, patients scheduled with the PA or the FNP only had certain presenting symptoms or complaints.  In other words, patients were not scheduled based on convenience, but based on the presenting symptoms or complaints. 

For physical therapists the question really becomes, when is it appropriate to delegate?  Every patient?  Certain patients?  After a certain time receiving services?  From my past experience it never appeared to me that any thought on with regard as to when to delegate.  It occurred based on how the receptionist could schedule the patient and NOT based on clinical needs.



TexasOrtho -> RE: Defining "Skilled care" (January 5, 2008 7:49:53 PM)

I guess that brings up the question of what delegating truly is.  I define delegating as telling my tech to set up a hot/cold pack, set up the UBE, or count repetitions.  Each patient that comes into the clinic has direct contact with me before, during, and after their visit.  I may not be staring directly at their knee for each of the 50 repetitions they perform, but I'm not sure that would be considered skilled care either.

So I guess it is a matter of perspective.  I believe the patient receives a skilled session of care where, in total, they work toward the goals of their treatment.  If I only billed for the portion of the care I considered "skilled", we could be in big trouble.  This could mean the first few minutes of an ergometer, initial reps of an exercise, etc...

It may sound hysterical, but I think could be a slipperly slope here.  If we differ on what we consider skilled, I guarantee CMS won't have trouble defining it for us and we might not like what we hear.  I believe we should be able to determine what is or is not skilled.  If you believe in using a PTA and your colleague does not, does this neccessarily mean the quality is significantly different?  I would think not.  You must determine what fits your practice pattern in your setting.  As long as it falls within the standards of care and evidence, we should have the autonomy to make these decisions.  The trouble is right now, we are bending over and allowing others to make these decisions for us.

I guess I am just frustrated right now. 



SJBird55 -> RE: Defining "Skilled care" (January 8, 2008 9:33:05 PM)

I supposed that I view the matter of "skilled" simplistically.  If the person is at functional level A and desires/wants to get to functional level X and has no clue how to go about achieving the desired level of function because of lack of knowledge, fear, pain, co-morbidities or whatever... well, I tend to believe that the person needs someone to create a game plan and the skill is in knowing what to do, why to do it and when to do it - along with knowing what not to do, why it shouldn't be done and for how long it shouldn't be done.  The person's available resources also is a factor to consider.  In some cases, especially with some of the elderly that I have coming in my doors - post chemo, dialysis, balance/falls - some of the actual components being performed appear to be simplistic, but my intent may be on improved proprioception and control when using a recumbent bike.  (I shouldn't have to be giving verbal cues about LE alignment or maintaining foot placement or placing and replacing a foot along with symmetrical force generation.)  Sometimes there are cardiac issues and I need the person to have a favorable cardiac response and improved endurance so the person can walk from a chair or dining table at home to the bathroom without becoming fatigued.  I suppose the main factor with some appearingly boring, redundant activities is whether there is a strong rationale for them.



Kaden -> RE: Defining "Skilled care" (January 8, 2008 10:17:35 PM)

 
"In some cases, especially with some of the elderly that I have coming in my doors - post chemo, dialysis, balance/falls - some of the actual components being performed appear to be simplistic, but my intent may be on improved proprioception and control when using a recumbent bike.  (I shouldn't have to be giving verbal cues about LE alignment or maintaining foot placement or placing and replacing a foot along with symmetrical force generation.)  Sometimes there are cardiac issues and I need the person to have a favorable cardiac response and improved endurance so the person can walk from a chair or dining table at home to the bathroom without becoming fatigued.  I suppose the main factor with some appearingly boring, redundant activities is whether there is a strong rationale for them. "

SJ, good post and I agree with your above take.  The question then is how do we bill for these services.?  1) if it is not direct contact then MC limits what we can bill for this person thus downplaying the thought, skill, and education that you used to make this decision.  2) if we are talking direct contact then when does an activity go from being defined as skilled care to non skilled care - 5, 10, 30 minutes? 

Unfortanutely , many guidelines/restrictions we now face are the reaction of enities responding to the improper billing practices by many in our profession.  I agree that in the examples SJ gave these all seem reasonable reasons to provide this type of "simple" service with good rationale, and good reasons to continue to see the patient until goals are achieved and define this as skilled care. 

However, the problem we face are those who provide uneeded services without good rationale simply to increase billabale units.  Such as putting someone on a modality, bike, etc just to add "fluff" time and increase units and cost.

Or the other clinic I tend to see is the sports performance/physical therapy clinics where there is always a grey area between transitioning from PT services to sports performance services.  I feel in these practices services such as improving golf swing, vertical leap, speed etc. are billed under PT codes when really they should be out of pocket expenses.  Our job as therapists is to rehabilitate a person back to prior level of function, not make them a scratch golfer or improve there vertical leap for sports performance.

Sorry for the ramble.  In closing, with continued challenges of making clinics profitable I think you will continue to see clinics walking that line or sometimes blatantly crossing it to help increase their bottom dollar.  In the long run all that does is hurt those of us practicing ethically and eventually results in more restrictions of our professional freedoms.  Can anyone say CASH PAY?



SJBird55 -> RE: Defining "Skilled care" (January 8, 2008 10:38:56 PM)

If a service is unneeded then obviously there is not a clinical rationale for the service.  If there is not a clinical rationale that is supported with literature and a progression toward meeting goals at a reasonable, expected timeframe is not occurring then the service isn't skilled.

Now, Kaden... if a patient's previous level of function was at a particular level of sport function, then I believe we should address any function below the previous level of function.  I have had individuals in the military and in the police force come to me specifically because they had an injury, went to another facility and weren't satisfied and were then recommended to contact me.  I did make darn sure that every single one of those individuals were able to adequately and safely perform their physical performance test.  Do I do design plans of care for other individuals with a focus on those types of goals?  No... but these particular individuals had to be able to perform at those levels for both their safety AND the safety of their team.  Same thing with high school athletes (generally the only kind of "athletes" that walk in my door)... when they are done with me, they are performing at their previous competitive level.  Reality is that documentation is all we have to support what we do.  Document well and there are no problems.

The amount of time performing an activity really isn't the factor in determining skilled or unskilled either.  If I have someone who I am treating and I want that person to be able to walk with a normal heel to toe gait patterning, then it may actually take 20 minutes of gait training on a treadmill with stop and go... verbal cues... demonstrations... movement breakdown or whatever for the person to learn.  Would 20 minutes be considered unskilled?  It all depends on what was documented.  I do know for motor learning to occur it takes a huge number of repetitions done correctly to create the motor program desired, so sure, it can be justified that something that appears unskilled is actually skilled AND the patient needs the time and repetitions to accomplish a new motor program.

In all honesty... I highly doubt that any nit-picky crap is going to occur with physical therapy services unless you have a patient that had a claim red flagged.  What would cause a red flag?  I'm not in that business, but in my mind.... well, if the claim had an ICD-9 code used and the number of visits or the number of particular procedures for that ICD-9 code happened to be say more than 2 standard deviations outside of the norm, I as a third party payor would probably want all documentation and would want to audit the services provided.  If the documentation was crap, I would choose not to pay.



TexasOrtho -> RE: Defining "Skilled care" (January 8, 2008 11:18:01 PM)

Great posts SJ and Kaden.  I agree that billing way outside accepted parameters are likely to get flagged for audit.  Anything else is indeed subject to what the therapist views as "skilled" care.  I tend to agree with SJ on this one.  I consider anything the patient is doing from the time their therapy begins untill the session is over (unless they are just sitting around waiting for me of course) as skilled.  The session is skilled care in that each activity is ostensibly a component of a skilled episode designed to achieve a functional goal. 

I'd like to think (as SJ does) that payors are unlikely to micromanage this process.  However, with the direct contact rules and not paying for thermal modalities, CMS has indeed recognized that some of our services are more skilled than others.  If they can make this assessment about modalities, I believe they can or will begin to make similar judgements on other codes. 

I'm sure physicians have had to fend off encroachments into their standards of care by payors.  Their numbers and $$ probably make them successful a good percentage of the time.  They are at the top of the pile though and really can afford to spend more resources on defensive tactics vs offensive tactics.  We are (while not at the bottom of the pile) certainly below physicians are are currently dividing our resources between offense and defense inappropriately.  Not only should we be pursuing greater roles within our own area of expertise, we should also be focusing on fending off some of these unreasonable constraints on our standards of practice.  I appreciate everyone's comments on this issue and welcome any other perspectives.



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