integrated rubric in electronic medical record for ... · evaluation code severity classification...
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Integrated Rubric in Electronic Medical Record for Evaluation Code Selection in Outpatient RehabilitationCraig Lee. PT, DPT
2018 MPTA Spring Conference
Objectives
Understand the historical perspective of therapy evaluation
Be familiar with the evaluation code severity classification
Gain insight into one unique education application for evaluation code selection
Learn about metacognition and its role in evaluation code selection
See the result of using metacognition in choosing evaluation code severity
Acquire strategies to impact correct evaluation code selection
Prepare for future implications of evaluation code selection
Historical Perspective
Physical Therapy started as reconstruction aides in the US
Began working in “out patient” settings
Missouri Delegation proposes PT evaluation
2013 CMS proposes severity classification for therapy evaluations
2016 final rules are published
2017 implementation of 3 severity levels for evaluation codes
Areas impacting complexity
History
Examination
Presentation
Clinical Decision Making
History
Age
Gender
Genetic factors
Cultural preferences Personality and attitudes Lifestyle
Social background
Education
Coping styles
Profession
Physical factors (handedness or BMI)
Environmental factors
Previous level of function
PT Treatment history
Examination
Body Structures:
Organs
Limbs
Joints
Ligaments
Tendons
Body Functions:
Mental
Sensory
Pain
Voice & speech
Neuromusculoskeletal
Movement-related
Activity limitations:
Executing tasks & actions
Self care
Meal prep
Personal hygiene
Participation restrictions: in IADLS such as in the community, church, charity work, etc.
Presentation
Stable & uncomplicated
Evolving with changing characteristics
Evolving with unstable and unpredictable
Increasing symptoms
Complicating and changing factors
Decision Making
Patient’s age
Time since onset of injury/illness/exacerbation
Mechanism of injury
Past med & sx hx
Co-morbidities and their impact on improvement
Prior level of function
Current level of function
Status of current condition
Patient’s cognitive status and safety concerns
Patient’s motivation
Patient’s home situation
Objective examination findings
Goals and goal agreement with the patient
Rehab potential (prognosis) and probable outcome
Expected progression of the patient
Evaluation Code Severity Classification
Low Complexity No personal factors and/or comorbidities that impact the plan
of care
Exam of body system(s) using standardized tests & measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, &/or participation restrictions
Stable and/or uncomplicated characteristics
Low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
Evaluation Code Severity Classification
Medium Complexity 1-2 personal factors and/or comorbidities that impact the
plan of care
Exam of body systems using standardized tests & measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, &/or participation restrictions
Evolving clinical presentation with changing characteristics
Moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
Evaluation Code Severity Classification
High Complexity 3 or more personal factors and/or comorbidities that impact
the plan of care
Exam of body systems using standardized tests & measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
Unstable and unpredictable characteristics
High complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
How did you educate staff?
History
Analyze the patient’s
medical and therapy
history
Low, Moderate, or High?
ExaminationEvaluate physical
impairments, activity limitations, and
participation restrictions
Low,
Moderate, or
High?
Presentation
Analyze clinical
presentation
Low,
Moderate, or
High?
Clinical Decision Making
Determine the clinical
decision making skills
required
Low,
Moderate, or
High?
Metacognition
What is it?
awareness and understanding of one's own thought processes.
"cognition about cognition", "thinking about thinking", "knowing about knowing", becoming "aware of one's awareness" and
higher-order thinking skills. … can take many forms; it includes knowledge about when and how to use particular strategies for
learning or for problem-solving.
Process to implement
Key Components Customizable EMR Large enough to devote staff to the process
PLANNING 2-3 months Leadership approval
Development Consultation with software engineers
Testing 4-6 weeks
TRAINING!
Roadblocks
Report errors
Inability to sign notes
Confusion
So What?
Prediction
Predicted Results
Outcome
Low Med High
Q1 46.70% 44.90% 8.60%
Q2 41.10% 50.50% 8.40%
Q3 38.30% 47.10% 7%
Q4 42.10% 50.10% 7%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Q1 Q2 Q3 Q4
Eval Code Results
Low Med High
Why are our choices important?
Now and in the future?
Accuracy is key now Assessment of the education process
Sets baseline data
Complexity does not impact reimbursement now but it likely will in the future
Significant changes in code selection in the future could be the red flag that results in review
Potential for fraud and abuse claims
Conclusions Education is Key
Metacognition
Accuracy is important to avoid future pitfalls
This process is complex and multifactorial
References
APTA. (2016). Quick Guide to the 3 Levels of Physical Therapy Evaluation.
Retrieved from American Physical Therapy Association: http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/NewEvalCodesQuickGuide.pdf
APTA. (2016). New Physical Therapy Evaluation and Reevaluation CPT Codes.Retrieved from American Physical Therapy Association: http://www.apta.org/PaymentReform/NewEvalReevalCPTCodes/
Childs JD, Whitman JM, Sizer PS, et al. (2005). A Description of Physical Therapists’ Knowledge in Managing Musculoskeletal Conditions. BMC Musculoskeletal Disorder, 6, 32.
Current procedural terminology CPT. (2011). Chicago, IL: American Medical Association.
Dicaprio, M. R., Covey, A., & Bernstein, J. (2003). Curricular Requirements For Musculoskeletal Medicine In American Medical Schools. The Journal of Bone and Joint Surgery-American Volume, 85(3), 565-567.
Gawenda, R. (2017, February 13). New Evaluation Codes and Percentages. Retrieved from Gawenda Seminars: https://gawendaseminars.com/2017/current-news-posts/new-evaluation-codes-and-percentages/
Guide for Professional Conduct. (2006). Physical Therapy, 86(1), 153-156.
Guide to physical therapist practice. (2003). Alexandria, VA: American Physical Therapy Association.
References
Higgs J, Jones M, (1995). Clinical Reasoning in the Health Profesions.Boston: Butterworth-Heinemann.
Jensen, G., Gwyer, J., Shepard, K., & Hack, L. (2000). Expert Practice in Physical Therapy. Physical Therapy, 80(1).
Medicare Payment Advisory Commission. June 2013 Report to the Congress: Medicare and the Health Care Delivery System. (2013, June). Retrieved March 12, 2017, from http://www.medpac.gov
Pinkston, D. (1986). Twenty-first Mary McMillan Lecture. Physical Therapy, 66(11), 1739-46.
Smith, G. I. (2016). Basic current procedural terminology and HCPCS coding. Chicago, IL: AHIMA Press.
Standards of practice for physical therapy and the criteria. (2006). Physical Therapy, 86(1).
The revised APTA code of ethics for the physical therapist and standards of ethical conduct for the physical therapist assistant: Theory, purpose, process, and significance. (2010). Physical Therapy, 90(5), 803-24.
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