rizzo final

PT may perform services without referral if:

-Graduated before 1998 and worked 4/6 last years with bachelors, OR has M.S.

- Pt. must have PCP

-PT must refer to PCP if PT does not help pt. get better/ improves within 30 days

continuing education

-Minimum of 20 hours/year

-Licensee responsible for maintaining certificates of completion

-State does not perform mandatory reporting; must respond with proof of continuing educations within 45 days of request if audited

- Continuing education waived for 1st time re-newers

role of PTA

-Assist in the practice of PT

-Pt. care without interpretation of referrals, initial or discharge evaluation or assessment, or determination or modification of treatment or discharge plans

-"Wellness care" conditioning, strength training, fitness, workplace ergonomics, injury prevention

charges against PTs in state practice act

o Crime during practice

-Steal money on street v. in clinic

o Illegal, incompetent, negligent conduct (malpractice)

- EX: Didn't take precautions that lead to fall

-Aggressive/ inappropriate treatment parameters

-Performed assessment or tx. Not within scope of PT

-Modality "accident" or negligence

o Aiding or abetting unlawful practice

o Not obtaining referral when needed

o Failure to register with DPH

o Fraud or deception in obtaining a license

o Engaging in fraud or material deception in practice

- Fraudulent insurance claims or billing for services not provided

o Failure to maintain continuing education requirements

o Violation of any other part of the practice act

Sexual misconduct includes:

o Engaging in or soliciting sexual relationships, whether consensual or not, while a PT or PTA/Pt. relationship exists

o Making sexual advances, requesting sexual favors or engaging in verbal or physical conduct in a sexual nature with patients

o Intentionally viewing a partially or completely disrobed patient in the course of tx if the viewing is not related to patient diagnosis or tx. Under current practice standards

precautions to protect against sexual misconduct

o Communicate intention of touch, point of assessment or treatment, what would make pt. most comfortable?

§ As PTs we have become desensitized to touch, what we interpret as professional touch can be interpreted by the patient as erotic or negative touch when: touch is unanticipated, a potential border of intimacy is crossed, touch breaches a cultural norm or belief.

o Observe

§ Pt's physical and facial reaction

o Leave door open and/or seek additional therapist (possibly same sex as patient)

o Methods:

§ Draping (sheets or towel)

§ Use of pillows

§ Let the patient know that you will remain professional under all circumstances but they are your concern: "I'm comfortable only if you're comfortable"

§ Release pt. to another PT or facility if patient is not comfortable with arrangement

what constitutes informed consent?

o Description of treatment

o Explain risks and benefits

o Timeframe (duration needed) of treatment

o Anticipated costs

o Reasonable alternatives

what constitutes abandonment?

· A PT may choose to withhold care due to a patient impairment, verbal/physical abuse, or conflict of interest

· Abandonment is usually only actionable if it occurs in "critical stage" of patient care (life or death)

o In non-emergent situation, patient has sufficient time to seek alternative care

· May be reasonable to simply give patient alternative facilities and PTs in situation when you have decided to withhold care

what to do if you are declining to see a patient again?

Decision to discharge when insurance benefits are exhausted but additional care is recommended is unethical and inconsistent with sound clinical judgment. PTs must:

o Advise pts that more therapy is needed

o Assist pts in insurance appeals processes

o Inform pts of free or low-cost community options for obtaining further care

o Inform of first-party/ self-pay options

o Decide whether continuation of a HEP is sufficient v. continued clinical sessions

· Avoid abandonment due to exhausted insurance benefits by:

o Being informed/ communicating with patient

o Altering plan of care (frequency, temporarily suspend tx, design HEP to supplement clinical session)

o Document to rationalize decisions

the parties that PTs need to protect against abuse

Minors

-Report to DCF within 12 hours of moment neglect is suspected

-Penalty for not reporting: Action against license

Impaired practitioners

-Impairment: emotional disorder or mental illness, drugs/alcohol, physical illness, loss of motor skills including aging

- Report to DPH

Persons with disabilities:

-Report to office of protection & advocacy for persons with disabilities within 5 days of suspected infraction

-Provider penalty: Fine of <500 dollars

Residents of long term care facilities

-Report to commissioner of social services within 5 days

-Provider penalty: fine of <500 dollars

Elderly

Other infarctions that must be reported:

o Illegal, incompetent, negligent care

o Improper use or distribution of prescription drugs

o Misrepresentation or concealment in obtaining licensure to practice

o Violation of any other CT Practice Act sections: Report to DPH within 30 days

fraud

·INTENTIONAL deception or misrepresentation for benefit:

o Knowingly billing for services not provided

o Altering claim forms for the purpose of receiving a higher payment

o Falsifying patient notes

o Use of unlicensed practitioners

abuse

payment for services when there is not legal entitlement; not intentional- simply did not know appropriate procedures:

o Misuse of coding on a claim

o Charging excessively for services

o Billing for services not medically necessary

Fraud v. Abuse: A fine line between the 2

o Fraud: Creating new patients, charges, documentation (more likely to be fraudulent)

o Abuse: charging for wrong codes when little benefit to do so (less likely) (Ignorant to fault)

waste

Like abuse, it is not intentional; other improper methods that cause unnecessary costs other than billing errors (NOT CRIMINAL... you just suck)

o Using expensive tests and procedures when evidence does not support them over less expensive ones

o Poor care coordination that results in prolonged complications in condition or readmission

o Ordering tests primarily to avoid malpractice

how to prevent fraud and abuse

make sure care is REASONABLE AND NECESSARY. Necessity is partially fulfilled by the fact that the services can only be performed by a SKILLED provider. This must be documented properly in order to be billable.

reasonable and necessary

o Whether the cost of treatment justifies chance that patient will reach desired level of improvement

o Whether the treatment will mitigate the patients risk of suffering an even worse outcome (more financial cost), if current condition is left untreated

o *All about money

NOT REASONABLE AND NECESSARY SERVICE when:

- Pt. treated by unqualified personnel

- Focus on recreational activities and not on functional problems

-Services not in POC (Plan of Care)

-Services not billable under Medicare

reasonable

- Within "standards of practice"

- Assessment and treatment methods

-Amount, frequency, duration is specified to verify if standard

-Treatments are specific and effective

-According to policies and best evidence

medical necessity

Treatments are contributing to functional limitations and participation restrictions

o PT considered necessary as determined by results of PT initial evaluation

o The pt. must require knowledge, clinical judgment, abilities of the PT

o PT care must be evidence-based and within standards of practice as means of restoring function, minimizing loss of function, or decreasing risk of injury or disease

-For medicare (and other third party payers), documentation of functional limitations/participation restrictions is key in establishing medical necessity

-Continued medical necessity is proven by documenting objective and functional improvements, as well as achievement of goals on daily and progress notes (frequent re-assessment)

· -Skilled: Skills required must be continually documented

- Requiring our knowledge - patient needing assistance and cuing to peform SAFELY and avoid COMPLICATIONS

o Descriptions of skilled treatments

§ Cuing, assistance need to perform activities safely

§ How safety could be compromised if not present to instruct

o Changes made to treatment

§ Progession/Regression of tx.

medicaid and direct access

-PT covered in CT but not in all states

medicare and direct access

- need to send certification to PCP and be signed in 30 days

-in hospital based outpatient= must get written approval by governing body of hospitals to be included on the list of practitioners who meet hospital's policies for ordering and referring patients to hospital outpatient services

progress note

o provide ongoing justification for medical necessity of treatment

o specify significant changes in POC : changes in level of assistance to perform task, changes in types of functional tasks, changes in types of assistive devices, improvement in functional task ability, pain level change

o smaller "snapshots" of how a patient is progressing as the POC continues

o Must be done on the 10th treatment day or the 30th calendar day from last certification, Re-Cert, or last progress note (whichever comes first)

· POC must be specified in Certification and Re-Certification(s)- NOT in progress notes. POC not in progress notes.

re-evaluation

NEW code; indicated when original certification is expired, a significant change in the patient's condition that warrants a change in POC, reached 90 day limit following initial certification

functional progress: what to report

-Must be documentation for every treatment day

-Date or service, all treatments performed, total treatment time, timed code total minutes, signature and professional identity

-Justify all treatments (Skilled, Necessary)

·

-Document objective measures (on progress notes and re-cert), used evidence based standardized tools and scales (Berg balance, 6MWT)

Assess objective measures and document progress:

o Changes in level of assistance

ex/Mod to min assist, less cueing

o Changes in types of functional tasks

ex/Went from only doing supine to sit, to doing sit to stand

o Changes in type of assistive device

ex/ Quad to straight cane

o Improvement in functional task ability secondary to reported pain level decrease

ex/ Pt able to sit 30 min as compared to 15 min as result of pain decrease from 8 to 3 on 0-10 scale

characteristics of goals

-specfic

-measurable

-achievable

-relevant

-time bound

also functional = be able to write one to improve function!

reliable and valid outcome measure (berg) why they are important to use in relation to Gcodes

G codes are based on valid and reliable measures, helps us come up with G code modifier- measure of impairment. How do you make decisions based on G codes.

G codes

o provide data on Pt's functional limitations and projected goal status

o Are non-billable codes

o Are an additional method to objectify patient Medicare function

o Correspond to a general functional limitation; code chosen depends on clinical judgment regarding body region affected and functional limitations observed

· G-codes used for current status, projected goal status, and discharge status

· Needs to have modifier that gives percentage to the functional limitation

o Determine the modifier based on clinical judgment: (Pt's level of functioning compared to pre-condition level, the magnitude of objective measure deficits, pt's level of functioning v. norms and standardized tests)

o Choose code depending on diagnosis, depending on note, depending on Pt. function.

defensible documentation

- Documenting "Skill"

o Type and level of skilled assistance needed

§ Manual. Visual, verbal cues

o Clinical decision making that took place

§ Explain why interventions were chosen

o Constant analysis of patient progress

§ Changes that represent progress (impairments and functional limitations)

o Constant linking of interventions back to function

3 types of supervision

-general supervision (apply to PTA depending on setting)

-direct supervision (apply to PTA depending on setting)

-direct personal supervision (apply to PT aide)

general supervision

the physical therapist is not required to be on site for direction and supervision but must be available at least by telecomminications

direct supervision

the physical therapist is physically present and immediately available for direction and supervision. the physical therapist will have direct contact with the patient during each visit, telecommunications DOES NOT meet requirement of direct supervision

direct personal supervision

the physical therapist or where allowable by law, the PTA is present and immediately available to direct and supervise tasks related to patient/client management. the direction and supervision is continuous throughout the time these tasks are performed. no telecommunications

tasks: carrying out instructions assigned by the PT or PTA, decisions not made by PT aide

best practices for preparing for and performing direct access

The APTA suggests the following to deliver quality direct access care:

-Continuing education (on Medical imaging, Pharmacology, Screening for medical disorders, Professionalism)

-Colleagues to consult with

-Having professional development plan

-Transitional DPT for those with lesser degrees

-Specialty certification (OCS, NCS, etc)

HIPAA basics

Federal Law, protects patient from unwanted release of protected health information.

Basic Guidelines:

-HIPPA "Privacy Rule"

the use and disclosure of individuals' health information—called "protected health information" (PHI) by organizations subject to the Privacy Rule — called "covered entities," as well as standards for

individuals' privacy rights to understand and control how their health information is used

-Applies to any covered entity that maintains or transmits protected health information in any form: electronic, oral, written, faxed, etc.

-Attempts to balance: flow of information between entities vs. protecting privacy

how to prevent HIPAA violations

-Computer display terminals turned away from the public

-Patient record/EMR areas off limits to patients

-Conversations about patients and their conditions should not be held in public places

-Information only released with proper authorization

OSHA basics

Golden Rule - "Every person should be treated as though they have an infectious disease."

Protection via:

Protective barriers, proper hand washing, appropriate disposal of hazardous waste, proper cleaning of contaminated areas