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CMS Medical Necessity - Determine Medical Necessity Before The Initial Evaluation
Oct 29, 2022
#physicaltherapymedicare #occupationaltherapymedicare #speechtherapymedicare
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0:00
Hey guys, what's going on? Tony here. So I wanted to reply to Ron's comment right here
0:07
You guys should be able to share or see my screen. And basically Ron was asking, you know
0:14
how would someone justify if the patient does or does not meet the medical necessity criteria
0:21
without first doing a PT eval? And I think that's a super important question
0:26
which by the way should be a covered service under Medicare. Ron, you're right. Totally right
0:33
on that. I agree with you. Here's the thing. Well, let's go to the second question first
0:38
And then he asks, you know, what functional measures did you use to determine that the
0:41
patient was within normal age equivalent gait velocity or had appropriate age equivalent
0:48
functional strength or was not at risk for falls? So I think he's maybe referencing David Bailiff's
0:54
video, which was a great video. But let's hit this topic. I'm going to grab full attention here. And
1:02
so this is usually what I say. I'd say the conversation starts at the initial point of
1:08
contact. Let's take two typical scenarios. New patient calls you, you've never worked with this
1:15
client before, you have no idea. They get you on the phone or in David's case, he even said the
1:20
I think it was the family member of the client got him on the phone and they have a referral
1:28
They're ready to sign up for therapy. Right. And so what do you do? Well, I know at our clinic
1:33
we always start with a telephone interview and the conversation goes something like this. It's like
1:39
you know, I welcome the total therapy solutions. And my name is Tony Martato. How can I help you
1:44
today? The person on the other end of the phone usually says, I've got a referral to start therapy
1:50
and I say, okay, that's great. Let me ask you a couple questions before we get started
1:55
What would we be seeing you for? And so, of course, they would tell me, you know, and I don't remember
2:01
David's story, but I'm going to say, let's say they say, well, I've got shoulder pain. Okay
2:05
excellent. Can you tell me a little bit about it? How did it begin? What makes it better? What makes
2:10
it worse? What kind of activities are you doing? You know, and so as we're going through this
2:14
initial telephone interview, which isn't a covered service, right? We know Medicare right now doesn't cover telehealth on a global scale
2:24
This is our kind of initial screening. It's not an evaluation. It's not a consultation
2:30
It a screening and we getting answers to our questions you know And so the client on the other end says like they answering well it painful and pain at night and it been going on for a couple months now and I tried cortisone and I tried medications and nothing making it better
2:47
Okay. Are you able to get dressed independently? Well, yeah, but it hurts
2:53
Are you able to sleep through the night? Well, yeah, but I wake up because I need to go to the bathroom, and my shoulder hurts
3:00
So we go through this long list of questions. Now, you can formalize those questions based on established, published CMS guidelines, right
3:10
But to give you an idea, so I would approach it from a medical necessity standpoint by saying
3:17
you know, well, tell me about your past medical history. Have you had any episodes of fainting or falling or dizziness
3:24
Well, no, no, no. Okay. Are you diabetic, hypertensive? Yes, yes. Are those conditions being medically managed
3:32
Are you on medication? Is your doctor supervising it? Yes, yes. Are you allowed to drive
3:38
Yes. Are you at risk for cardiac complications for a stroke? Well, no, nothing like that
3:45
Okay. So you're painting a picture. You're gathering evidence. And I would encourage everybody to have a list of questions
3:54
Let's say 10 questions. yes, no questions that clearly allow you over the phone to start to determine medical necessity
4:05
And so if we're looking at a picture of somebody who's experiencing symptoms consistent with
4:10
vertigo, they're experiencing some dementia, they're having episodes of fainting or falling
4:16
they're having blood pressure drops, right? Clearly a medically necessary physical therapy
4:22
evaluation is in order and something that we would do as a covered service. But if they're dealing
4:28
with some persistent pain that isn't necessarily getting better, but it's also not stopping them
4:34
from doing the basic activities of daily living, they're getting dressed, they're feeding
4:39
they're bathing, they're active in the community, they're going to church, they're spending time
4:44
with family, they're doing the things they need to do. They're just not doing them as well as they
4:50
would like to do them, I think we can start to build a case to route this person to a medically
4:57
necessary PT evaluation or to a non-medically necessary PT evaluation, the latter of which is
5:04
required by most state practice acts, right? But that's not a covered service under Medicare. If you
5:10
saw the video from earlier today there a difference between what Medicare will cover and require and what your state practice act may cover or may require So we need to have that initial screening process in place based on established guidelines based on questions and
5:27
answers. And then let's just say, for example, patient answers everything correctly, right
5:34
We get them in, we say, you know, I'm happy to work with you based on your answers. It does not
5:40
sound like this is something that will be covered by Medicare. I realized that your physician gave
5:45
you a referral, but the physician doesn't establish Medicare guidelines. Medicare does
5:53
Certainly, we'd be happy to work with you, but since it's not a covered service
5:57
this is the cost. If you'd like to schedule the evaluation, we can go from there
6:02
Let's say they schedule the eval. They come in, we start the evaluation. All of a sudden
6:08
the person sitting in front of me is very different than the person who is answering
6:12
the questions on the phone. And I determined as a physical therapist during this process that
6:18
hey, wait a minute, this is way more complex. There's all these tissue healing deficiencies
6:24
and pathologies and all this other stuff that the patient didn't realize or communicate clearly
6:31
This is truly a medically necessary physical therapy evaluation that has to be provided by
6:38
a participating or non-participating contracted physical therapist, you stop, you direct them
6:46
appropriately. You say, look, this actually is different than what I was expecting based on our
6:51
conversation on the phone. I really think you need to go see a contracted physical therapist because
6:58
this should be covered by Medicare. And that's it. But if you don't have printed, published
7:05
guidelines, policies, procedures in place to support your decision, then you're flying by
7:12
the seat of your pants and you're going to be in trouble. And I think that's what's lacking for so
7:17
many people in private practice is you know in your brain what's important, what's medically
7:22
necessary, what's not, what the criteria is, but you don't have anything to support those decisions
7:27
in terms of policies and procedures. So Ron, to answer the original question, I think you start
7:35
with a telephone screen or an in-person interview based on specified criteria you
7:42
determine medical necessity and then you perform the evaluation either as a
7:48
covered service or as a non covered service and in terms of what functional
7:52
outcome measures or assessment tools you use you use whichever is appropriate if I got somebody with back pain I might use a back index or optimal from APTA If I got somebody with neck pain there a neck index there upper extremity functional index lower extremity
8:06
photo, like there's no end to the functional outcome measures you can use. I tend to
8:14
I'm not a fan of age related norms personally, for something like this, there's just such a vast
8:20
array of what a person could do. I've got a gentleman right now. He works out with me three
8:28
to four days a week at the CrossFit class that I go to. He's in his 70s. He's had a shoulder
8:34
replacement. The dude is doing pull-ups, full body weight pull-ups. I've got people 20 years
8:41
junior to him who can't do a push-up from their knees. Age-related norms are pretty well useless
8:50
in my general opinion, I want function. Could you lift three bags of groceries from the ground
8:58
and carry them into the kitchen before you were her? Yes. Can you do them now? No. Do I think you
9:05
can get back to carrying those groceries after our programming? Yes. Boom. Prior level of function
9:13
current level of function, goal level of function specific to the individual in context of the
9:19
individual's life. That's what I'm looking at. Carrying, lifting, pushing, pulling. I like
9:25
throwing, change of position, super basic functional stuff. But I think things that every
9:32
human should be able to do. And that could be part of your questionnaire, right? It could be
9:38
hey, can you get on the ground and can you stand up? No. Why? I'm not strong enough. Okay
9:44
I am experiencing vertigo. Okay. Those are very different scenarios, right? So, Ron, I hope that answers your question. I agree there is a criteria that needs to be in place to establish medical necessity, but I think there has to be a screening process first
10:04
I don't think the physician can adequately determine medical necessity. I think it takes a physical therapist, an occupational therapist, speech therapist
10:15
So we should be in the driver's seat of that. And I think we can be as long as we make our decisions based on published, established guidelines
10:23
Guys, I hope that was helpful. If you have more questions and want to talk about this more, I'm an open book
10:29
I don't have all the answers. I don't claim to, but I'm happy to do whatever I can to help you find the answers
10:35
I'll catch you on the next video
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