I’ve been doing consultative analysis with Physical Therapist offices for 15 years. Let me share with you 7 habitual mistakes I consistently run into and some helpful hints to make more money for private practice owners
1. TherEx – Yes, the description of Therapeutic Exercise makes it sound like if I’m doing an intervention with a patient which involves exercise, that I should count it as TherEx. Many times, you are using Exercise Equipment or doing large body movements, you should be using Therapeutic Activity (not Exercise): Dynamic movements to improve physical performance. Other times, you are doing movement education and guided movement interventions. Neuro Re-ed better describes this intervention far better than TherEx.
Here are a couple additional reasons to use all three movement intervention codes (TherEx, TherAct, Neuro Re-ed):
- Therapeutic Activity has a higher payment, which means you are causing the company you work for, to lose out on additional profit by coding everything as TherEx.
- Neuro Re-ed specifically includes giving feedback to the patient during movement activities to improve the quality of that movement. Feedback can be in the form of verbal cues, devices or even tape.
- The irony in this, is that when a therapist uses TherEx, they feel that by using that code all the time that they are being safe and avoiding the auditors. Using TherEx, to a therapist, is like being at home in front of the fireplace; slippers and bathrobe are on while you sit in your high backed chair, hot cocoa in your hand, petting the dog as you read from your favorite author to the crackle of a fire. The exact opposite is happening as you may be over using TherEx compared to your peers and encouraging a payer review.
2. Fixed Rate Payers – There are a lot of terms for fixed rate payers: fixed rate, per diem, flat rate, capped payers, etc. Billing folks use these terms interchangeably and it gives the practice owner the feeling that “No matter what I do, I will get paid the same per patient visit”.
Keep in mind that most of the time per diem, fixed rate, and capped payers are not paying you a flat rate (although everyone thinks of them as flat/fixed rate). More typically, they are paying a capped maximum per day which still requires you to bill a certain number of timed units per day to qualify for the maximum capped amount for that day. I always get a kick out of the shock a company goes through when we improve the payment per visit for them on what they thought were ‘fixed rate/per diem’ payers.
3. Forgetting Assessment and Management Time at the beginning of treatment– Provider work is broken out into Pre-Time (setup and prep), Intra-Time (performing the procedure), and Post-time (documentation and discharge). I find that almost all therapists are forgetting to include all components of their time in the form of assessment and management time.
Assessment and management time includes getting the patient ready for treatment – how they have been since the last time you saw them, how they are feeling, and hands-on assessment you need to do (you’re asking how the patient has been since the last time you’ve seen them, how they are progressing, ask about their HEP, etc.)
4. Counting all your Intra-Time correctly – I’m betting, even if you don’t feel so hot about assessment and management time before and after you put your hands on your patients, that at this point you are probably feeling pretty good about how you count your ‘Intervention’ (Intra-Time) correctly.
Most of your time will be spent in Intra-Time (The hands-on treatment time when you actually do the interventions). Intra-Time includes all your one-on-one assessment and management time. This includes assessing the patient’s progress since the last visit, clinical judgment to establish the day’s treatment, and it starts with your first professional interaction with the patient OR caregiver. This first interaction can start in the waiting room (ie., when you go out and ask them “Hi, how have you been since I last saw you on Tuesday?”. Even though you are standing in the waiting room, one-on-one time has started since your assessment and management time has started. Here are a couple additional items most of the time not counted in intra-time:
- The time you spend on the phone with the referring physician. As long as you have engaged with the patient and the patient is still with you, you should count any time you spend calling the patient’s referring physician.
- Document while the therapist is with the patient. Any time spent documenting, while the patient is in the office, counts as intra-time. When therapists don’t do their notes during the appointment it almost makes me sick as to how much time and money they just lost the practice. Any documentation done as ‘home-work’ does not qualify to be counted towards billable units.
5. Forgetting Assessment and Management time at the end of treatment – I’m not even going to make a sarcastic comment.
This can occur at the end of the visit day and can also occur between interventions. This includes documentation and discharging the patient from the procedure and the day’s treatment. This includes elements of both assessment and management time and practice expense.
6. Using In and Out Time – I’m going to lose it if I see another therapist document in and out time on every single visit.
Don’t use “In and Out” time (requirement changed in 2007). Yes, A couple non-Medicare payers still ask for this (like Work Comp), so indicate this if needed, but don’t indicate the In and Out time for every payer and visit as you are only providing an auditor with even more detail to scrutinize against your scheduling program (Now they better match perfectly and it’s not even a requirement). Heaven forbid your front desk shortens, extends or moves the appointment around.
The only time requirement that needs to be indicated is the start time of the appointment, which will be in your scheduling system, so you don’t need to document the appointment’s length… I just lost it!
7. Counting Time for Each Intervention – Lots of therapists believe that they should count and document time spent on each individual intervention.
This belief comes from using systems that force the therapist to document the amount of minutes they do for each intervention. The systems then calculate all of the units and sometimes automatically select ‘TherEx’ for the unit calculation.
Even mentioning this scenario gives me a small burst of tension. Here’s why:
- It causes the therapist to under-count their assessment and management minutes. Thus cheating the organization out of substantial profits that they should have received had the coding been done correct.
- It automatically selects TherEx, when a lot of the time the exercises performed should have been TherAct or Neuro Re-ed again cheating the organization out of profits.
- It’s annoying to the therapist by forcing the therapist to break up their exercise regimen each time they finish 1 of the interventions so that they can go over and document how many minutes they just spent.
- How do you count partial minutes? What if several of the interventions are 2.2 minutes, 3.5 minutes, 4.6 minutes, etc.? What we find is that the therapist ends up siding on the conservative side, which then leads to a reduced amount of minutes compared to the actual time spent. Say it with me “Loss in profit”.
- Giving a number of minutes per intervention when not required gives a reviewer a lot of unnecessary detail to look at. By providing the number of minutes per intervention you open yourself up to additional scrutiny during an audit.