Tom Ambury, PT, CHC
Attendees will understand the key components of the initial evaluation Attendees will understand the importance of
the initial evaluation in establishing the skilled need for therapy
Attendees will understand the key components of documenting skilled need Provide a Post Test
1. D 2. D 3. B 4. C 5. A 6. C 7. A 8. C 9. C 10.A NGS LCD: L26884
Paint the picture of the pt’s impairments and functional limitations requiring skilled interventions
Establish the prior level of function to assist in establishing the patient’s potential for improvement
Describe the skilled nature of the treatment
Justify the intensity of therapy is medically necessary for the individual patient’s condition
Clearly document Total Timed Code minutes and Total Treatment Time to justify units billed
Identify each intervention/modality provided to justify coding
Skilled Therapy: Skilled therapy services may be necessary to improve a patient’s current
condition, or to prevent or slow or prevent further deterioration of the patient’s current
condition
◦The goal of the initial evaluation is to demonstrate skilled therapy is necessary for the patient’s current condition. Or to put it another way;
◦Are skilled therapy services necessary to restore or maintain the patient’s current condition based upon their presentation at the time of evaluation?
Skilled Therapy:
◦Rehabilitative Therapy: Does the patient have the potential to substantially improve and will the improvement occur in a generally predictable and reasonable period of time.
Maintenance Therapy:
◦Treatment by the therapist is necessary to maintain, prevent or slow or prevent further deterioration in the patient’s functional status.
Performed by a therapist
Documents the medical necessity of the course of therapy through;
◦Objective findings and, ◦Subjective Self-Reporting ◦The conditions to be treated
◦Any complexities that make treatment more difficult or lengthy
Yes, we have to describe the impact of complexities so it would be clear to a medical reviewer
History of Present Illness: Tell the story of how the patient came to be seeking therapy NOW including:
◦Diagnosis(es) relevant to the patient’s needing therapy
◦Date of Onset: Be specific – On or about ◦Objective and specific Prior Level of Function ◦How the patient’s impairments affect their Current
Level of Function
◦A thorough pain assessment if pain is present
Relevant PMH
◦Prior diagnostic testing: X-rays, MRI results, etc. ◦Prior Hx of therapy for the same diagnosis Social Support/Home Environment
◦Live Alone or with someone ◦Steps to enter/railing
◦Number of floors in living space ◦Stairs inside the home
◦Where’s the laundry, bedroom, bathroom ◦Drives or community transportation
Pt is a 70 y.o. M presenting to PT today s/p R TKA, 12/30/14. Pt reports as a result of his recent surgery he has constant R knee pain rated at 5/10 now, 2/10 at Best, 8/10 at Worst. Pain has been improving since onset but continues to disturb his sleep.
Prior Level of function: Independent in Gait without an assistive device on all surfaces for community distances. Independent in ADLs including bathing/grooming/dressing/homecare/meal prep/and driving for community integration
Current Level of Function: Pt performs gait on level surfaces with s cane and Supx1, negotiates stairs with s cane, 1 railing and Sup x 1 using a step to gait. Pt is unable to walk community distances. Pt is unable to drive. Pt reports needing assistance from his wife for bathing/dressing/meal
prep/household activities. Pt reports being able to sit for up to 15 min and stand for up to 5 min.
PMH is significant for OA, Type 1 DM, and CAD with CABGx3. Medication list reviewed with patient and in chart
Social: Pt is married and lives with his wife in a 2 story house with 5 steps to entrance and 14 steps to the second floor for his bedroom and bath.
Prior Therapy: Pt was seen during his hospitalization for his initial therapy and did not receive home health therapy.
Pt is a 70 y.o. M who presents to PT with a complaint of LBP. Pt reports having a 10 year Hx of LBP and was in his usual state of health until on or about 9/1/14. Reports the
exacerbation of his pain began for no apparent reason and has been worsening since the onset. Reports initially trying self treatment without success. He saw his MD on 12/1/14 who tried adjusting his medications and ordered MRI. According to the patient the MRI demonstrated spinal stenosis.
Pt describes his pain as constant, worsening since onset, and disturbs his sleep. Reports sx start on the R side of his low back area and travel down his R leg to the calf. Pain is better with medication, sitting, and heat. Pain is worse with lying, standing, walking, and riding in his car. Pt rates his pain now at 2/10 in sitting, 10/10 at worst, 2/10 at best. Reports his pain will cause his R leg to buckle with walking.
Prior Level of Function: Prior to onset of Sx the pt reports being I with gait on all surfaces without an Assist device, unlimited ability to stand for Dressing/bathing/grooming/meal prep/community integration
Current level of Function: Pt performs gait with a R walker and is unable to stand for more than 5 minutes for performing
showering, shaving, meal prep activities. Pt is unable to drive
PMH: 10 Hx of LBP with L5-S1 discectomy in
2013, Pt has no other relevant PMH. Current medications include Norco, celebrex, fentanyl patch. Medication list reviewed with pt and in chart.
Social Hx: Patient is married and is the primary
caregiver for his wife. They live in a single story house with 4 steps to enter, bed and bath on main floor, laundry in basement with 12 steps to access.
Prior Therapy: Pt reports having no prior PT for
Having established how the pt came to need therapy, now we have to determine if the patient has impairments that typically respond to skilled therapy interventions
What objective measures would typically be completed for a pt s/p TKA.
◦Standard Functional outcome i.e. LEFS
◦Balance Assessment: Tinetti, Berg, Timed up and go, Functional Reach, 4-Square
◦ROM: Bilateral, joint above and below ◦Strength: Bilateral, joint above and below ◦Gait analysis
◦Transfers: sit to stand, supine to sit, car, etc ◦Wound Status
◦Edema
Standard Functional Outcome, i.e. ODI, perhaps a LEFS
Lumbar/Thoracic Evaluation: Don’t forget your special tests
LE evaluation Neuro Testing Gait Evaluation Balance Testing
The evaluation must be specific to the patient. In the objective testing identify and objectively measure all impairments you anticipating treating.
Avoid “canned” statements that appear with every patient
Most important part of the Evaluation. Use the Assessment to:
◦Summarize the impairments you intend to treat ◦Explain how the impairments impact the patient’s
ability to perform their normal functional activities ◦Explain what impact, if any, the patient’s
complexities might have in the course of treatment ◦Provide your professional opinion on the patient’s
restorative potential if you expect functional improvement
Pt presents with objective impairments in R LE ROM, muscle weakness, Scar Adhesions, balance, poor neuromuscular motor control R knee, gait, and transfers. These impairments are typical for patients who are s/p TKA and the impairments respond to physical therapy interventions. As a direct result of the identified impairments the patient has objective functional deficits as indicated by a LEFS score = 60% impairment. In addition, the patient’s Hx of Type 1 DM and CAD will require the skill of a therapist to monitor and insure the patient safely performs therapeutic program. The patient is a good rehab candidate to achieve their goals and I anticipate the patient requiring a prolonged episode of care due to the potential effects DM on healing.
Pt presents with a significant objective functional decline as noted by an ODI score of 60% suggesting a complete disability due to LBP with R LE Pain to the lower leg. The severity of the pt’s pain severely interferes with the pt’s ability to walk, transfer, and perform his primary caregiver activities for his wife. Also contributing to the pt’s severity of pain and functional decline are objective impairments in postural strength with postural muscle guarding, lumbar ROM, R hip muscle weakness, and impaired balance. These are typical impairments for patients with LBP and respond to skilled therapy interventions. Pt is a good rehab candidate to achieve his stated goals, however due to the chronicity of his LBP with the inherent soft tissue adaptive shortening, pain avoidance behaviors, and disuse atrophy of postural muscles, I would anticipate a longer than typical episode of care.
MUST be specific to the patient MUST be objective and measureable MUST be functional representing the
functional activities specific to the patient Cover the entire duration of therapy.
◦If you estimate the duration of therapy to be 6 weeks then the goals represent the patient’s functional status at discharge
◦If the duration of therapy is 90 days as allowed by Medicare, it would be good documentation practice to have interim goals.
Increase AROM R Knee flex to 115 to allow I stair negotiation using reciprocal gait without a railing Increase R LE strength to 5/5 to allow I negotiating
stairs using reciprocal gait without a railing Improve balance to restore I gait without an assist
device on all surfaces
Restore I ability to perform bathing, grooming. Pt will be able to sit/stand for over 1 hour for
community integration
Pt will be able to drive himself for community integration such as shopping and worship. Discharge FLR goal G8979, Severity Modifier CH
based on LEFS 0% disability
Patient will perform caregiver activities for his wife with pain no greater than 2/10.
Patient will be able to drive for 30 min with 2/10 pain for community integration. Patient will safely walk without an assistive
device with I on all surfaces for grocery shopping and re-entering his house.
Pt will be able to carry laundry up/down stairs safely without a railing with max pain of 2/10 Discharge FLR Goal G8979 CJ based on ODI =
20%
Select skilled interventions based on clinical literature and clinical experience to treat specific impairments
◦List all interventions anticipated for treatment ◦Relate to cpt codes
Select a dosage of therapy needed to resolve the impairments, restore function, and achieve goals
Must be individualized for the patient Do not underestimate the power of your Plan
of Care!
Pt will be seen 3x/week x 8 weeks ◦PT Evaluation 97001 ◦Therapeutic Procedures 97110 ◦Neuromuscular Re-Ed 97112 ◦Manual Therapy 97140 ◦Therapeutic Activities 97530 ◦Gait Training 97116 ◦Ice Pack 97010
Provide an intervention for each impairment to be treated.
Pt will be seen 3x/week x 12 weeks ◦PT Evaluation 97001 ◦Therapeutic Procedures 97110 ◦Neuromuscular Re-Ed 97112 ◦Manual Therapy 97140 ◦Therapeutic Activities 97530 ◦Gait Training 97116
◦Electrical Stim Unattended G0283 ◦Hot/Cold Pack 97010
Evaluations that are not specific to the patient ◦Canned statements in each evaluation
◦Non-specific goals or generic goals, i.e.
“Decrease Pain”
“Improve ROM”, “Strength”
“Restore Prior Level of Function”
OK to use templates just edit
Important that the evaluation accurately represent the patient just evaluated
Providing therapy when improvement is not substantial.
Providing the same intensity of treatment to every patient.
Post Quiz Answers will be gone over at the start of the Transform Your Documentation, Part 3 on Tuesday 1/20/15!
Email: [email protected]
Telephone: 888-680-7688
