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Pt tiered eval
- 1. Determining Patient Complexity: A Physical Therapy Perspective By Nico Olson-Studler, SPT, CPT
- 2. Objectives ● Understanding complexity levels ● Why tiered model The tiered evaluation model allows us to demonstrate our value as PTs!
- 3. The Eval
- 4. Updated CPT codes (97161) Low Complexity Evaluation (97162) Moderate Complexity Evaluation (97163) High Complexity Evaluation (97164) Re‐evaluation
- 7. Show me the evidence! ● Low: 46% ● Mod: 45% ● High: 9%
- 9. M25: joint disorders M54: dorsalgia (back/spine pain) M79: soft tissue disorders R26: gait and mobility abnormalities
- 10. New CPT codes Components: 1) History 2) Examination 3) Presentation 4) Clinical decision making
- 11. Complexity rubric Complexity Level: Low Complexity Moderate Complexity High Complexity History: 0 1-2 3+ Exam: 1-2 3 4+ Presentation: Stable Evolving Unstable
- 12. Patient History ● Past Medical History ● History of current illness ● Prior level of function ● Physical characteristics ● Cognitive/Psychological context ● Social situation ● Living environment ● Personal factors
- 13. Examination ● Body structures and functions ○ Musculoskeletal ○ Neuromuscular ○ Cardiovascular/Pulmonary ○ Integumentary ○ Orientation & Alertness ● Activity limitations ● Participation restrictions
- 14. Body systems (Exam) ● Musculoskeletal system ● Neuromuscular system ● Cardiovascular/Pulmonary system ● Integumentary system ● Orientation & Alertness
- 15. Documenting the Examination ● Activity Limitations: ○ Mobility ○ ADLs ○ Self care ● Participation Restrictions: ○ Home/Community ○ Work/School ○ Public access/transportation ○ IADLs/other responsibilities
- 17. Presentation • Stable, uncomplicated, and predictable • Evolving, changing • Unstable, unpredictable, sig. safety concerns
- 18. Clinical Judgment: History + exam + presentation clinical judgment clinical decision making value!
- 19. Avoiding miscoding ● Clear, objective documentation ● Lowest common denomenator ● Equal reimbursement ● No incentives with upcoding ● Use clinical judgment ● Consult the cheat sheet ● Consult colleagues/supervisors ● FREE CEUs on APTA, MedBridge sites
- 20. Things to consider.. ● Timing for complexity ● PT specialty ● Varying clinical judgment ● Not a perfect system ● Tx complexity levels
- 21. Dot phrase At date of evaluation, the medical and functional past medical history includes the below 2***3***4*** factors; influencing the patient's participation in the plan of care. 1. Diabetes, affecting tissue health 2. Chronic nature of pain, affecting recovery process due to physiologic changes to body 3. Unstable living situation, affecting ability to perform home program 4. Few friends/family in area for support 5. Psychological factors complicating overall health and recovery process 6. Cognitive factors Examination performed today identified the following 2***3***4*** body structures/functions to be addressed in therapy. 1. *** 2. *** 3. *** 4. *** Activity limitations include ***. Participation restrictions include ***. Based on standardized assessments, special tests, clinical judgment and stable***evolving***unstable*** clinical presentation, the patient is classified as minimally***moderately***highly complex. The developed plan of care is consistent with the problem(s) and needs of the patient, family and/or caregivers
- 22. Questions?
- 23. Case scenarios *Courtesy of Portland Providence Medical Center Rehabilitation Team*
- 24. References ● “Common Questions from our New PT and OT Evaluation Codes Webinar.” WebPT. Dec 2016. Print. < https://www.webpt.com/blog/post/common-questions-from-our-new-pt-and-ot-evaluation-codes-webinar > ● “Documentation Tips for Physical Therapy Evaluation Code Selection.” American Physical Therapy Association. 2016. Print. < http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/DocumentationConsiderationsSupportingEvalu ationCodeSelection.pdf> ● Elliot, Carmen “New CPT Evaluation Codes are Here.” PTinMotion. Feb 2017. Print. < http://www.apta.org/PTinMotion/2017/2/ComplianceMatters/> ● Evans, Wanda. “Compliance Matters: Documenting the New Evaluation Codes.” PTinMotion. March 2017. Print. < http://www.apta.org/PTinMotion/2017/3/ComplianceMatters/> ● Hibbert-Iaccobacci, Michele and Lindgren, Valerie. “New Physical Therapy Evaluation Codes for 2017: Moving Toward Value Based Payment.” Compliance Corner. Mitchell. Aug 2017. Print. < https://www.mitchell.com/mitchellnews/id/1495/new-physical-therapy-evaluation-codes-for-2017-moving- toward-value-based-payment>
- 25. References (cont.) ● Jannenga, Heidi. “What 500,000 Evaluative Notes Told Us About the New CPT Codes.” WebPT. Aug 2017. Print. < https://www.webpt.com/blog/post/what-500000-evaluative-notes-told-us-about-the- new-cpt-codes> ● Picard, Kathleen. “New Payment system: Evaluation Codes for Physical Therapy.” PowerPoint. Picard Consulting. 9/22/16. Print. <http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/NewPaymentSystemWebinar_EvalCod esforPhysicalTherapy.pdf> ● “Quick Guide to the 3 levels of Physical Therapy Evaluation.” American Physical Therapy Association. 2016. Print. <http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/NewEvalCodesQuickGuide.pdf> ● “Tiered Physical Therapy Evaluation and Reevaluation CPT Codes.” American Physical Therapy Association. 2017. Print. < http://www.apta.org/EvalCodes/ >
Editor's Notes
- So let’s talk about the PT Eval. We can all agree that completing a thorough eval is integral to achieving positive outcomes in our pt’s POC. It is a dynamic process in which the PT must gather the pertinent medical history from the chart and compare it to the clinical findings collected from the pt’s examination. How many times have you walked into a room and thought to yourself, “Wow, that was not what I was expecting,” for better or for worse. We then evaluate oour examination to establish a PT diagnosis, determine the pt’s prognosis, write therapy goals, and develop a POC reflecting our expected outcomes for the pt. Prior to January 1st, 2017 there was a single code billed for a PT evaluation. Due to advancement in Medicare policy, a new system of tiered evaluation coding was implemented to reflect a pt’s level of complexity and medical severity. “The Physical therapy evaluation continues to be a dynamic process in which the PT makes clinical judgments based on data gathered during examination. Examination includes taking a comprehensive history, performing a systems review, and conducting tests and measures. The PT evaluates examination findings, establishes a physical therapy diagnosis, determines the prognosis, and develops a plan of care that includes goals and expected outcomes, interventions to be used, and the anticipated plan of care. What's different with the 3 new evaluation codes is that they are tiered to reflect the complexity of the evaluation—low, moderate, or high.” http://www.apta.org/PTinMotion/2017/3/ComplianceMatters/ “The physical therapy reevaluation code should be reported when the PT reexamines the patient or client to evaluate progress, modify or redirect intervention, and/or revise anticipated goals and expected outcomes. Reexamination may be indicated more than once during a plan of care” Discontinued the use of 97001 (Eval) and 97002 (Re-Eval) as CPT codes since January 1st, 2017 HIPAA required code set Copyright/published by: American Medical Association (AMA)
- These 3 codes then replaced 97001 for Medicare and commercial payers, except for Worker’s Comp (which remains to be billed as 97001). CPT: current procedural terminology
- The CMS implemented the tiered evaluation system to replace the previously service-based PT Eval code 97001. This new coding system serves to more precisely support the medical necessity of skilled PT services based on the therapist’s determination of complexity of a patient’s condition. This allows the therapist to justify payment of services based on the patient’s medical necessity, as well as the required clinical decision making performed by the therapist. And as we all know, each patient presents differently and ought be treated accordingly. The new structure of evaluation allows therapists to use clinical decision making to determine a patient’s complexity in regards to their PMH and presentation of their current illness, thus allowing us to demonstrate our value as medical professionals. “ Insufficient and improper documentation are red flags for government and private payers that may prompt further scrutiny of a provider's billing practices.” http://www.apta.org/PTinMotion/2017/3/ComplianceMatters/ Thorough and complete eval Determine complexity - Accurate documentation and communication Demonstrate value - address variation in care Better determine patient management and establish POC
- The APTA recommended that the new evaluation codes follow a stratified fee schedule, meaning that the higher the complexity of the patient, the more Medicare should cover the cost of the evaluation session. However, the CMS (Centers for Medicare and Medicaid Services) rejected this recommendation and stuck to their originally proposed model of equal pay for all complexity levels, at least for the meantime while the new roll out. The CMS did however increase the value of the re-eval code slightly. The CMS made this decision in and effort to prevent fraud and abuse of up-coding, while recognizing the need for a “trial period” for therapists to become acquainted with and adjust to the new coding changes. The CMS believed that the novelty of the updated coding structure would cause rampant upcoding amongst well-intended therapists while they were still gaining familiarity with the new system. The CMS predicted that the pattern of evaluation coding would follow that of a bell curve, projecting that 50% of evals would be billed as Moderate complexity, while 25% as Low complexity and another 25% as High complexity. However, prior to rolling out the new system, the CMS stated that they could not predict with a “high degree of certainty” that the utilization of the tiered eval codes would maintain “budget neutrality.” In other words, they weren’t sure how things would shape out. So during these initial stages of coding change, the CMS is gaining a better understanding of the population receiving PT services to therefore arrive at a more accurate conclusion of the effectiveness of the tiered coding system. Nevertheless, Medicare’s contemporary coding system has helped to develop a more value-driven payment method. It is up to us as therapists to accurately document our evaluation findings to demonstrate our value, skill, and expertise as health care providers. The APTA is on board, acknowledging these changes a “step in the right direction” in regards to payment reform. Further changes should be expected in the near future regarding tiered reimbursement for evals and potentially also treatment sessions. “As part of APTA's longstanding efforts to pursue a new payment system that fairly reflects the expertise, skill, and responsibility of physical therapists in caring for their patients and clients, the association and its collaborators developed this 3-tiered system of CPT evaluation codes to replace the current single code that covered all physical therapist evaluations.” https://www.mitchell.com/mitchellnews/id/1495/new-physical-therapy-evaluation-codes-for-2017-moving-toward-value-based-payment http://www.apta.org/PaymentReform/NewEvalReevalCPTcodes/ “Payment Based on Quality and Outcomes = Value to Patient and the Payer” “Assessment tools at the front end, outcomes reported at the back end begin to differentiate how patients are managed for potential development of reformed payment model” *Chocolate ganache tiered cake*
- WebPT = largest rehab therapy-specific EMR system on the market → able to collect ample industry data (500,000 or ½ million eval reports) No way to guarantee budget neutrality, because CMS did not know for certain if their projections of 50-25-25% would pan out as expected, hence why they opted not to offer higher pay for more complex patients (assigning tiered reimbursement rates for levels of complexity) Most eval = low-mod, so based on this CMS would save money since not spending much on high evals → however not quite the case.. See next slide
- Trend of Mod complexity for older population Spikes in High complexity for early childhood and elderly age ranges Since individuals in the age group of 65+ y/o use Medicare as their primary insurance, this means that the majority of evals billed to Medicare in comparison to privately insured patients, are of high complexity. This spells trouble in paradise since it could affect Medicare’s willingness to proceed with a tiered reimbursement model if they’re having to pay more to cover their “more complex” clients, imagine that! With Medicare being the trend setter that it is, this could also mean that private insurance payers may also reject the notion of tiered reimbursement as well. More women evals than men. Author believes it’s d/t masculinity trait of “being tough” and not honestly expressing the severity of their condition, leading to fewer Mod-high complexity cases.
- M25: joint disorders M54: dorsalgia (back/spine pain) M79: soft tissue disorders R26: abnormalities of gait and mobility R26 accounts for the largest relative amount of Mod and High complexity patients- likely due to the fact that patients with diagnoses related to gait and mobility impairments usually present with multiple concurrent injuries and co-morbidities, therefore are more complex conditions. Keep in mind that these trends are new and therapists are still getting used to the new system, so there are bound to be hiccups here and there. Data matters and will influence future health care (Medicare) decisions and policies. Aim to always accurate categorize your patient’s complexity level to uphold our reputation as doctorate-level healthcare professionals. https://www.webpt.com/blog/post/what-500000-evaluative-notes-told-us-about-the-new-cpt-codes
- Components: • Patient history (comorbidities, personal factors) • Examination and the use of standardized tests and measures • Clinical presentation • Clinical decision making, leading for establishment of POC
- Complexity rubric
- IMPORTANT: because medical and personal factors influence how the patient experiences illness and disability. Review of co-morbidities that impact the POC: Past medical history (impacting current mobility) History of current illness (impacting current mobility) Prior level of function (baseline functional level vs. current mobility) Physical characteristics: BMI, stature, anthropometrics, etc. Emotional/cognitive: anxiety, depression, bipolar, dementia, confusion, etc. Social situation: assist available at home, community engagement (work, school), domestic & civic life Living environment: barriers to d/c (stairs, amb long distances, living alone) Personal factors: sex, age, education, coping styles, behavior pattern, experience/attitude of disability, cultural preferences, past/current medical/illness experience, learning styles, compliance with interventions Personal factors that exist, but do NOT impact the POC, should not be included in determining complexity level
- Components of the examination
- A Review of Body Systems includes the following: • Musculoskeletal system: the assessment of gross symmetry, gross range of motion, gross strength, height, and weight • Neuromuscular system: a general assessment of gross coordinated movement (eg, balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning) • Cardiovascular/pulmonary system: the assessment of heart rate, respiratory rate, blood pressure, and edema • Integumentary system: the assessment of pliability (texture), presence of scar formation, skin color, and skin integrity For communication ability, affect, cognition, language, and learning style: the assessment of the ability to make needs known, consciousness, orientation (person, place, and time), expected emotional/behavioral responses, and learning preferences (e.g. learning barriers, education needs) *Use of standardized tests and measures to determine the functional outcome of the pt
- Activity limitations: Difficulties an individual may have in executing a task, action, or activities (eg, inability to perform tasks due to abnormal vital sign response to increased movement or activity). -Mobility: changing or maintaining positions; walking; carrying; handling objects; etc. -Other ADLs: household tasks, assisting others, etc. -Self care: hygiene, dressing, etc. Participation restrictions: Problems an individual may experience in involvement in life situations (eg, inability to engage in community social events due to exhaustion). -Participating in domestic life -Participating as a member of a community -Participating as a student or employee -Accessing public transportation or other services -Performing IADLs such as grocery shopping or laundry -Caring for children or other dependent family members
- ICF model developed by the WHO: establishes the standard language and framework that outlines the components of the PT examination in regards to the pt’s health and well-being. Their mission is to include the body, the individual, and society (personal and environmental factors) when describing function and disability. Here are some examples
- Patient interview (nature) Observing patient response to exam (behavior) • LOW: Stable, uncomplicated, straightforward, problem‐focused Most eval + d/c patients, no fall risk WNL/WFL strength, AROM, pain, sensation, balance, mobility, etc. • MODERATE: Evolving, characteristics of patient’s condition are changing, complaints, and/or cognitive deficits Declining mobility status: increased weakness, WB changes, etc. Increasing/peripheralizing pain or symptoms Irregular/inconsistent symptom presentation Fall risk • HIGH: Unstable, characteristics of patient’s condition and are unpredictable, and/or significant cognitive deficits affecting safety Medically unstable: red flags present Unpredictable behavior: poor cognition, poor insight into impairment, impulsive Abnormal/fluctuating pain/symptoms/lab values – orthostatics, low Hg, low INR Significant changes in level of assist required due to worsening impairments High fall risk
- History + Physical Exam + Clinical Presentation → all contribute to support decisions made reflecting Clinical Judgment. Which is then used to make a clinical decision of complexity. This process of formulating our clinical judgment is demonstrated through effective documentation of clinical findings. Clinical judgment and clinical decision making are determined by our synthesis of all the components of the pt evaluation, as well as developing an individualized POC according to the pt’s complexity. Thus demonstrating our value as PTs!
- Assess and communicate patient complexity clearly and objectively The code that is submitted should reflect the lowest common denomenator of complexity level across the 3 domains of history, exam, and presentation. Even if 2/3 categories are considered “high” and 1/3 is considered “low”, then the eval defaults to “low complexity”. Remember: the new CPT codes are still billed as a group and therefore receive equal reimbursement (so it’s OK if you make a mistake now until reimbursement potentially changes, but practice using accurate coding to the best of your ability each time), not yet billed individually although likely to head in that direction No incentives with upcoding, although it is Medicare’s goal to in the future penalize therapists for misconding evals In retrospect you feel that you miscoded an eval and it was blaringly obvious, it is possible that it could trigger an audit. Consult the cheat sheet Use clinical judgment Ask yourself: Would an auditor would be able to identify all the criteria necessary to justify the level of complexity you chose? Consult colleagues/supervisors FREE CEUs on APTA, MedBridge sites Online-self paced course 0 CEU credits, but FREE 30 min MedBridge video, FREE APTA’s pocket guide $6 Published articles in PTinMotion magazine, APTA and WebPT websites Coding and payment guide for the Physical Therapist (2018) = $180
- Evals are NOT timed codes although general timing estimates: 20 min (Low), 30 min (Mod), 45 min (High), 20 min (Re-Eval) Re-Eval = revised POC, d/t significant change in pt’s condition PT specialty: pelvic floor vs. NICU vs. performing arts specialty areas of PT that PTs have varying degrees of comfort and experience treating pts on-going debate between PTs on how this should or shouldn’t affect our clinical judgment in what we perceive as “highly complex” because the complexity rating is truly based on data collected from the pt about the pt. Remember that this is not a perfect system and is likely to change again in the near future. We are still within Medicare’s “trial period” in which they are still trying to work out the kinks. Throughout the country there has been insufficient education and mentorship regarding these changes. Originally it was proposed the CMS would implement a similar tiered complexity assignment model to treatment sessions starting on Jan. 1st, 2018. However, the project has been placed on hold while further date has been collected and analyzed.