Introduction to Direct Access Troy Bourgeois, PT, DPT Patrick Cook, PT, MPT, OCS Katie Brittain, PT, DPT, MBA Joseph Shine, PT, DPT
2016 Fall Meeting September 9‐11, 2016 Baton Rouge, LA
Welcome to the 2016 LPTA Fall Meeting! We appreciate your participation and want to welcome you to the LPTA Fall Meeting! If you need assistance, the Meeting Staff can be identified by their yellow name badges. They will be happy to help you in whatever way is appropriate. EXHIBITS ARE OPEN FROM 7:00 P.M. TO 8:30 P.M. ON FRIDAY AND 7:00 A.M. TO 11:00 A.M. ON SATURDAY.
For entry to the Exhibit Hall, you must wear your meeting name badge. Please make a point of visiting all of our exhibitors, thereby qualifying for the exhibitor prize drawings that will be held at 10:45 a.m. at the break on Saturday morning. Please wear your name badge to ALL Meeting functions. It identifies you as an authorized participant in the Meeting activities and amenities. Name badges are in several colors:
PT Members PT Nonmembers PTA Members PTA Nonmembers Resident PT/PTA Members Resident PT/PTA Nonmembers Students Spouse/Guests Exhibitors Exhibit Pass Only LPTA Staff
White Purple Gold Gray Ivory Salmon Blue Pink Green Tan Yellow
NOTE: Lunch is provided for all meeting registrants at the Saturday Business Meeting. Nonregistrant members are invited to attend, but should make other luncheon plans outside of the meeting room, or purchase a luncheon ticket for $25. Please do not bring any food or beverages into the Business Meeting with you.
Exhibitors Baton Rouge Physical Therapy- Lake Inspired Medical, Inc. LightForce Therapy Lasers Physical Therapy Provider Network Preferred Therapy Providers, Inc. Reliant Rehabilitation Synergy Care, Inc. Tara Therapy Therapy Center Therapy Management Corporation University of St. Augustine for Health Sciences Work Saver Employee Testing Systems
Crowne Plaza Meeting Room Layout
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Save the Date! National Student Conclave October 27-29, 2016 Miami, Fl PPS Annual Conference October 19-22, 2016 Las Vegas, NV
Combined Sections Meeting February 15-18, 2017 San Antonio, TX LPTA 2017 Spring Meeting March 10-12, 2017 Hilton Lafayette Lafayette, LA LPTA 2017 Fall Meeting September 8-10, 2016 Crowne Plaza Baton Rouge, LA
Louisiana Physical Therapy Association 2016 Fall Meeting
Introduction to Direct Access Troy Bourgeois, PT, DPT Patrick Cook, PT, MPT, OCS Katie Brittain, PT, DPT, MBA Joseph Shine, PT, DPT
Friday, September 9, 2016
Introduction to Direct Access
September 9, 2016
Introduction to DIRECT ACCESS ‐ ‐ ‐ ‐
Board Perspective: Patrick Cook, PT MPT OCS Payment: Katie Brittain, PT DPT MBA Preparing for DA Patient: Joseph Shine, PT DPT Panel Discussion ‐ ‐ ‐ ‐
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Troy Bourgeois, PT DPT, Movement Science Center Patrick Cook, PT MPT OCS, Peak Performance Katie Brittain, PT DPT MBA, Partners in Physical Therapy Joseph Shine, PT DPT, Performance Physical Therapy
Patient Access Patrick Cook, PT, OCS, FAAOMPT
Where do we go from here?
With or Without Referral With referral • No changes to the way these patients are treated
Without referral 1. Do they fit into subsection C –
Treat as before
2. PT is point of entry into healthcare system –
Follow 37:2418.B
37:2418.B.(1) • A. No changes – PT responsible for all care • B.(1) Without prescription or referral, a physical therapist may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy and may perform physical therapy or other services provided in Subsection C of this Section.
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Introduction to Direct Access
September 9, 2016
37:2418.B.(2)(a)
37:2418.B.(2)(a)
• (2)(a) For the treatment of a condition within the scope of physical therapy, other than under the circumstances provided for in Subsection C of this Section, a physical therapist may implement physical therapy treatment with or without a prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic if the physical therapist meets one of the following criteria:
• (i) The physical therapist has a doctorate degree in physical therapy from an accredited institution. • (ii) The physical therapist has five years of licensed clinical practice experience.
37:2418.B.(2)(a)
37:2418.B.(2)(b)
• Within the scope of practice of PT • implement physical therapy treatment with or without a prescription or referral • Other than circumstances in subsection C • Must meet one of two criteria
• (b) If, after thirty calendar days of implementing physical therapy treatment pursuant to this Paragraph, the patient has not made measurable or functional improvement, the physical therapist shall refer the patient to an appropriate healthcare provider. The board shall take appropriate disciplinary action against any physical therapist who fails to refer a patient pursuant to this Paragraph.
1. Doctorate degree from accredited university 2. 5 years of experience
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Introduction to Direct Access
September 9, 2016
37:2418.B.(3) and (4) • (3) No physical therapist shall render a medical diagnosis of a disease. • (4)(a) The provisions of this Section shall not be construed to have any effect on the provisions of R.S. 23:1121 or R.S. 23:1203.1 • (b) The provisions of this Section shall not be construed to have any effect on the monetary limit provided for in R.S. 23:1142.
37.2418.C No Changes to this section: C. Physical therapy services may be performed without a prescription or referral under any of the following circumstances: (1) To a child with a diagnosed developmental disability pursuant to the child's plan of care. (2) To a patient of a home health care agency pursuant to the patient's plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness. (5) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention.
Medical Diagnosis
Medical Diagnosis
• 37:2407.C. In seeking and receiving reimbursement for services, an initial physical therapy evaluation as defined in this Chapter shall be considered a physical therapy diagnosis and shall not constitute the practice of medicine.
• Physical Therapy Evaluation―the wri en documentation of physical and cognitive findings, objective tests and measurements, patient history, pertinent medical diagnosis, signs, symptoms, and the PT’s interpretation of such findings, as well as goals and a treatment plan or program as defined in §123. The initial physical therapy evaluation shall be documented and signed by the PT performing the evaluation within seven days after performing the evaluation. An initial physical therapy evaluation shall not be documented or signed by a PTA or any other personnel.
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Introduction to Direct Access
Diagnosis • Prescription―a request for diagnostic or therapeutic physical therapy procedures or regimen subscribed by an individual lawfully authorized to make or give such an order or directive. • Referral―a request for physical therapy evaluation or treatment made by an individual lawfully authorized to make such request. • Part of the “prescription” has been a request for diagnostic physical therapy procedures
September 9, 2016
Functional Improvement • Not specifically defined in practice act • Board acts as a jury of your peers • Validated outcome measures – Pain scale – Functional activities – Questionnaires
• Compare with prognosis and expected changes
Thank You! Any questions about the Practice Act?
Direct Access: Billing and Coding Pearls Katie Brittain, PT, DPT, MBA, CLT LPTA Practice/Payment Committee Chair
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Introduction to Direct Access
What do we expect?
September 9, 2016
Objectives 1.Discuss 10 recommendations related to payment when providing care to a direct access patient. 2.Identify potential barriers for receiving payment. 3.Identify potential opportunities for expanding your payment model in a direct access state.
#1 EDI Electronic claim submission: • Claims can reject before they get to the insurance company. • Call your clearing house to ensure claims will not reject without a referring NPI number
#2 Intake Financial Agreement • All patients should sign intake forms that they agree to be financially responsible. • Do not put too much information on one page. • Consider creating a form that is specific to direct access in the event of a denial due to requiring a referral. • Think about the agreement’s tone.
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Introduction to Direct Access
September 9, 2016
#3 Verify benefits
#3 Verify benefits
Non Medicare Insurance
Medicare
• Yours: – Look at your provider contract to check for language regarding the need for referral.
• Theirs: – Question: “Is a referral required as a condition of payment?” – Check eligibility and question each patient’s policy requirements. – Ask the question when working claims.
• No script needed. • No MD visit required. • Plan of Care must be certified by physician practitioner or non physician practitioner (NPP). – Nurse practitioner, clinical nurse specialist, and physician assistant.
• Name and NPI number of the certifying physician/NPP on the claim for therapy services.
#4 Medical vs PT Diagnosis • Medical – disease, disorder, or condition at the level of the cell, tissue, organ, or system
• Physical Therapy – identify the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person
#5 ICD 10 • Don’t forget about the 7th character especially for an initial encounter – A‐ initial encounter when a patient is receiving active treatment – D‐ encounter occurring after the active phase of treatment, when a patient is receiving routine care during a period of healing or recovery
– S‐
complications or conditions arising as a direct result of an injury
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Introduction to Direct Access
#6 Matching ICD 10
September 9, 2016
#7 Documentation and Medical Necessity
• Medicare stated last October: – There will be a 1 year ICD 10 grace period. – Once the grace period is over, it will be necessary for the PT and MD/NPP to document the same ICD 10 code as a condition of payment. – No updates in 2016. – Consider keeping an open line of communication with referral sources.
#8 Cash pay and HIPAA • Are you a covered entity? • Do you transmit any information in an electronic form in connection with a transaction for which HHS has adopted a standard?
• Document a review of systems and red flag assessment. • Make sure that your documentation meets medical necessity standards.
#9 Opportunity • Direct Access open doors for opportunity outside of traditional practice and payers: – Litigation – Cash Based Programs – New locations – Events
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Introduction to Direct Access
#10 Resources • • • • • •
September 9, 2016
Get out there and get going
LPTA APTA Peers Attorneys Coders Other experts
Contact me with questions Preparing for DA Patient Katie Brittain, PT, DPT, MBA, CLT LPTA Practice/Payment Committee Chair 3221 Ryan Street, Suite D Lake Charles, LA 70605
[email protected] 337‐439‐3344
Joseph Shine, PT DPT
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Introduction to Direct Access
September 9, 2016
What are the concerns? Preparing for DA Patient ‐ ‐ ‐ ‐ ‐ ‐
Concerns of independent practice Specialized forms Documentation Screening Tools Functional Improvements Marketing
Direct Access Specialized Forms • Tell them what to expect • Billing and payment • Communicating with a physician
• What if I miss something? – PT is science and an art, just like medicine – Things are missed, but have to be vigilant – Making the right PT diagnosis
• I do not want to be sued? – Understanding your professional and personal abilities
• How do I know what is best practice? – Publications from APTA, attending LPTA meetings, getting involved in your profession
Direct Access Specialized Forms • You have chosen to self refer yourself to physical therapy services without a referral from another health care professional. We will perform a detailed evaluation, develop a treatment plan, and provide physical therapy services. Medical imaging is not part of you evaluation process. At anytime you can ask questions about your services, discuss any additional services, and you are always free to discontinue your services.
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Introduction to Direct Access
September 9, 2016
Direct Access Specialized Forms
Direct Access Specialized Forms
• Our office will verify your policy benefits for direct‐access services to physical therapy with out a referral. We strongly encourage you to do the same with your policy. We will pursue payment based on the information we receive from your insurance carrier, and will appeal any denial. It is important that you understand that your insurance company may not cover all charges incurred and that the insurance company do not guarantee payment. You will be responsible to any unpaid balance not covered by your insurance policy.
• Under direct access to physical therapy, we may not be required to notify any medical provider. If you are a Medicare plan we will need a plan of care endorsed by a physician. If your plan requires a prescription we will have a plan of care endorsed by your physician. • If you would you like us to inform a physician on your behalf concerning out physical therapy findings, please list his name and office address below:
Direct Access Specialized Forms • Have to outline release of medical records • Protection of health care information: HIPPA • Cash based fees
Name:___________________ Location:____________
Documentation • Evaluations – complete evaluation • Progress notes – detailed • Using standardized form every two weeks, or before end of 30 days. • Discharge Notes • Patents Returning back for Direct Access
• Work Comp and Legal Cases
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Introduction to Direct Access
September 9, 2016
PT Diagnosis • • • •
Diagnosis are made by specialist PT Diagnosis leads to our Treatment Plan Prescription vs Medical Diagnosis What is needed to treated – Medicare is signed Plan of Treatment – Workers Comp: Depends on relationship, patient rights – Private Insurance: Individual Policies – Private Pay
Screening Tools • Use Standardized Medical Intake – You have to ask the questions
• Knowing the Cardinal Signs of Medical Emergency • Use Standardized Screening Test
Cardiac Screening • • • • • •
Family Hx Blood pressure and Pulse Weakness/Fatigue Lack of Energy Depression Chest, Pain, UE pain
Cancer Screening • • • • • • • •
Age > 50 Prior History #1 (Family History) Weight Loss > 10 lbs Night Pains, Unrelenting Pain Symptoms > 30 days Fever Abnormal lumps, unexplained painful spots Feels something is wrong
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Introduction to Direct Access
September 9, 2016
Urinary Dysfunctions • • • • • • • •
• • • • • • • •
Complaint of back pain without insidious onset Urinary Flow or Retention / Control Color Frequency Urgency Pain LE Edema Pain in mid back (kidney), pressure over bladder
GI Screening • • • • • • •
Complaint of pain along the GI symptoms Swallowing Heartburn Indigestion Rebound pain Fever / Chills / Sweat / Relief with sitting Color and Texture of Stool
Infection
Fracture Screen
Fever / Chills Night Pains Fatigue / Malaise (unexplained illness/uneasiness) Nausea / Vomiting SOB Decreased appetite Abscess Rubor (redness), Calor (increased heat), Tumor (swelling), Dolor (pain), and loss of function
• Swelling or bruising over a bone • Deformity / Malalignment • Pain in the injured area that gets worse when the area is moved or pressure is applied • Loss of function in the injured area • Non traumatic: Cancer / Osteoporosis • Stress fracture of the foot
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Introduction to Direct Access
September 9, 2016
Ottawa Ankle Rules
Deep Vein Thrombosis • Subjective Report Burning in calf, can’t stand/walk long
• Cancer, Trauma, Recent Surgery • > 50 yo, Immobilization, Prolong Sitting (flying) • Pain, Redness, Swelling, Warmth, Engorged • Ultrasound studies, Stockings, Anticoagulants
Abdominal Aortic Aneurysm • Complaint of Abdominal Pain – Mid line, throbbing, pulsating pain
• • • • • •
> Men, 50‐60 yo Hx of BP, Cholesterol Recently doing heavy work (gym) Obesity Smoking, Emphysema Family history
Vertebral Artery • • • • • • •
Complaint of Neck pain plus…… Vision (see floaters, altered vision) Swallowing causes pain Trouble speaking Dizziness Fainting VA test, Cervical Extension, Hugs
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Introduction to Direct Access
Cauda Equina Syndrome Complaint of LBP and Saddle Pain / Anesthesia Cough / Sneeze Bowel / Bladder Numbness / Tingling Sciatica Poor Balance / Stumbling / Standing from Sitting • Often in 40‐50’s
• • • • • •
Screening Cervical Spine
September 9, 2016
Canadian Cervical Rules
Medical Testing / Emergency
• Starts with question – Positional, “floaters,” feeling light headed/blackout, does your neck feel unstable, swallowing
• Vertebral Artery Test
• X‐rays: Urgent Care, Primary Care, Ortho, Imaging facility
– Extend, sidebend, rotate ipsilateral side
• Alar Ligament Test – Medial to apical ligament, from odontoid to condyles of skull
• Transverse Ligament Test
• Blood test: Primary Care, Independents • Psychology, Cardiology, Oncology specialist
– Medial tubercles of lateral masses of C1, transverses odontoid
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Introduction to Direct Access
Functional Improvements • Standardized Tools – – – –
Pain Diagram with Visual Analog Scale Oswestry Cervical and Low Back Dallas Pain Questionnaire FOTO computerized
• Other Options – – – –
DASH: Disability arm shoulder hand Upper extremity functional index Lower extremity functional index Hybrid Form
September 9, 2016
Pain Diagram and Analog Scale Very Basic
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Introduction to Direct Access
September 9, 2016
Functional Improvements Hybrid Form of Standardized Tools
Marketing Direct Access • • • • •
Current Patients: always your best advocates Past Patients: Events: Advertisement: Physicians: form an alliance – Specialist: PCP, Cardiologist, Psychology, Oncology – Imaging / Blood test
Professionalism • • • • • •
Be up front with your patient Ethics and Board Rules Documentation Refer out and co‐treating Discharge when appropriate Wellness is not treatment
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Introduction to Direct Access
Get Started • • • •
Get your staff educated and aware Practice like a professional You will learn as you progress Expect bumps in the road
September 9, 2016
Panel Discussion ‐ Troy Bourgeois, PT DPT, Movement Science Center ‐ Patrick Cook, PT MPT OCS, Peak Performance ‐ Katie Brittain, PT DPT MBA, Partners in Physical Therapy ‐ Joseph Shine, PT DPT, Performance Physical Therapy
Where do we go as a profession from here!
Thank You
• Governmental Affairs – Membership – Advocacy at the Capital – Fair Copays – Imaging – Make up of Boards – What else?
Any last questions?
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