Summertime PT Fun Test-see you how you do
It is time for the first annual “are you smarter than a PT regulator?” test. We will start out with a sample question and then get right into it. Please do not look at the bottom for the answers and explanations until you have completed the test. Be honest, post your scores and your thoughts. If you are too scared to post them on the blog, please email me privately. Academic programs-particularly interested in how your students performed. Perhaps it might be better for them not to take this since it might scare them out of the profession!
I realize that PT’s are exam phobic. However, I thought this was the best way to illustrate the absurdities in our industry. Sorry in advance for the length of this blog post.
Sample Question:
Which of the following are the only providers under medicare’s rules to have a physician signed plan of care:
A. Chiro’s
B. Optometrists
C. Physical Therapists
D. Dentists
E. Proctologists
The answer is C of course. Why don’t we fight against this? who knows. In fact the recent change from 30 days to 90 days has caused more confusion and questions than it has answers, particularly the physicians who are now asking questions about plans of care that last 10 weeks!!
Medicare Physical Therapy Economics:
1. Which of the following received the most payments in medicare for PT services:
A. Hospital
B. Skilled Nursing Facility
C. Physical Therapist Private Practice
D. Physicians
E. Outpatient Rehabilitation Facility
2. Hospitals have always been exempt from the medicare cap. Between 2004 and 2006 which provider setting has seen a decrease in percentage of medicare beneficiaries seen in their setting:
A. Skilled Nursing Facility outpatient (medicare part B)
B. Hospital Outpatient
C. Physical Therapist Private Practice
D. Outpatient Rehab Facility
E. All but C.
3. Approximately 8.5% of the 43 million medicare patients annually access PT. What percentage of the 179 billion part B medicare budget goes to PT?
A. 2%
B. 4%
C. 6%
D. 8%
E. 10%
4. There were approximately 4% more PT’s seeing medicare patients in 2006 than in 2004. This resulted in the following:
A. about a 4% rise in physical therapy expenditures in 2006
B. a 10% rise in 2006 sending all kinds of “red flag” to medicare about PT usage
C. There was no change in expenditures between 2004 and 2006
D. There was more than a 5% decrease in PT expenditures between 2004 and 2006
E. None of the above are true
Medicare Regulations:
5. Which of the following are not allowed as billable time under medicare:
A. A ventilator dependent skilled nursing patient is in being treated by a student under supervision of a PT.
B.. A ventilator dependent skilled nursing patient is being treated by a therapist extender under supervision of a PT.
C. An ATC working as a therapist extender is counting the number of straight leg raises of a medicare patient.
D. A physical therapist assistant working solo in an outpatient rehab facility is performing manual therapy on a patient.
E. PTA working solo in a outpatient rehab facility is doing soft tissue massage
6. A PT is working with a medicare patient. After examination and applying a clinical prediction rule, the PT decides to do a manipulation thrust technique on a patient which after looking at his clinic supplied (and CMS approved) stopwatch took 5 min. Concurrently, a therapist extender is working with a non medicare patient counting the number of straight leg raises. What is the correct billing?
A. Wow, too difficult to tell-so I will take the safe route and bill it as “group” or not charge at all
B. A no charge on the thrust technique since it took less than 8 minutes.
C. Assuming the pre and post treatment times are added to the stop watch, it is a safe assumption that it took 8 minutes BUT the concurrent patient was being supervised by the PT so the thrust technique is “group” therapy.
D. Manual therapy thrust techniques are not allowed on medicare patients-at least not in my clinic.
E. This scenario is stupid. It is immoral, unethical, and impossible to manage more than one patient at a time and the fact that you have even used the words therapist "extender" is a disgrace to our profession-am done with this stupid quiz that I am failing.
7. Which of the following are part of a typical state practice act in PT:
A. Certification plan
B. 8 minute rule
C. Restriction on billing for work performed by students in an outpatient setting
D. Explicit definitions of PT and PTA as the only providers of service
E. None of the above
8. Which of the following according to CMS are not allowed to make “clinical judgments”?
A. PT
B. PTA
C. ATC
D. Therapist Extenders
E. All but A
9. Which of the following payors most restrict the clinical judgment of a PT?
A. CMS
B. United because they pay the least.
C. Work Comp
D. Private payors in general
E. None of the above.
10. Many hospital PT’s are very concerned that effective July 1, PT extenders under direct supervision will not be allowed to work with medicare patients and have their “minutes count”. Which National Organization has lobbied for the continued use of therapist extenders in the part A environment:
A. APTA
B. NASL
C. AARP
D. ASPCA
E. NAFTA
11. After Nuclear Power plants, which industry is the most regulated:
A. Health Care.
B. Construction.
C. Insurance
D. Financial services
E. Pharma
12. Which of the following will most help Tiger Wood’s with pre-op exercises?
A. Self-help DVD
B. An exercise sheet of knee exercises given by a physician with a popular anti-inflammatory as the sponsor of the exercise handout
C. a Nintendo Wii
D. A therapist extender under supervision of a PT after a clinical exam by the PT
13. A Senior PGA tour player who has medicare has just been referred to PT for knee pain. Which of the following are not considered billable?
A. A therapist watches a self help DVD with a patient
B. A PTA reviews the exercise sheet given by a physician
C. PT plays Nintendo Wii bowling with a patient
D. an ATC (therapist extender) under supervision of a PT and after a clinical exam by the PT is working with the patient on straight leg raises
E. all of the above are billable under medicare
14. All of the following are supervision terms used by medicare except:
A. General Supervision
B. Direct Supervision
C. “line of site” supervision
D. “same room” supervision
E. All are terms used by CMS
15. Hospitals are exempt from medicare’s cap for outpatient PT. This is because:
A. Hospitals are the preferred provider of CMS
B. Hospitals have shown that they are the most cost-effective providers of outpatient PT
C. Hospitals have always believed that all PT should be “one on one”
D. Hospitals have the lobbyists with the biggest bucks and biggest influence in Congress.
E. Nobody really knows-just another stupid rule by the government
16. The medicare cap for PT is combined with speech and language pathologists while OT has its own cap. The reason that it is combined is:
A. Everybody knows speech therapists really want to be PT’s so they just went ahead and combined them
B. Allows co-treatment of PT and Speech without regards to total dollars
C. So few outpatients need speech that they figured “what the hell, let’s just combine them”
D. They knew they couldn’t combine PT’s with OT’s or there would have been a hell of a dogfight
E. Nobody really knows-just another stupid oversight by the government
ANSWERS:
1. C. PTPP dominate the medicare outpatient physical therapy world with a 35% market share with hospitals having 21% and physicians 9%. Although PTPP is by far the largest, it cannot be determined how much of PTPP is truly outpatient PT owned by PT versus outpatient PT that is owned by MD’s. We do know that the biggest rise between 2004 and 2006 data was PTPP and it is presumed to be physician owned growth since that is when MD practices were allowed to start applying for their own PTPP numbers. In fact, physician data to CMS actually decreased during this same time due to the transition of MD practices billing “incident to PT” to PTPP.
2. E. All but PT in private practice have seen a decrease in the number of medicare beneficiaries in their setting. Right wrong or indifferent, physical therapy private practice is where the medicare “action” is yet the ridiculous superimposed rules by CMS are making financial viability in a private practice challenging to say the least. I am sure there are several reasons why medicare patients don't go to hospital outpatient clinics for PT even when they have a financial incentive to do so.
3. A. In fact, it is less than 2% at 3.05 Billion.
4. D. Per CMS data PT expenditures went from 3.23 B to 3.05. They are trying to credit the medicare exemption process. Grade them an F for terrible analysis. This is surprising since hospitals are exempt from the cap but then again, hospitals are losing substantial market share in outpatient PT.
5. C. CMS allows students and therapist extenders on part A medicare but not part B. Don’t try and figure it out-logic won’t work. I have no trouble with the therapist extender in these settings as I fundamentally believe that PT’s can and should be in the position to make those determinations. Unfortunately, the trend within our profession is to eliminate all therapist extender positions within an outpatient setting under the mistaken belief that the care is “unskilled” or that all PT requires “clinical judgment”. Their stupid argument goes something like this: Why should an insurance company pay for services that are “unskilled”? Is taking height, weight, and blood pressure skilled? (ok, sorry about a “quiz within a quiz”). Does medicare pay for those services in conjunction with a physician’s exam? The only factor that should matter to any payor is whether or not the PT is acting within their scope of practice. Just because something is “skilled” is not the benchmark for payment as any profession has to have support services and a complete inability to pass the cost of the support services along so that a therapist can be more efficient destroys the utilitarian ability of a provider and the ability to be the most cost effective. Don’t all professionals have support staff that assists in an overall delivery? Lawyers use paralegals or clerical help that they bill for as do accountants and almost all other “real” professions. On the one hand, we want to be the Vision 2020 Doctoring “profession”. On the other hand, we want to police ourselves out of an industry under the mistaken belief that we need to "clean" ourselves up or that it is immoral professionally to use support help. Let’s fight for consistency in all settings which allows PT’s to use their judgment in accordance with their practice acts and keep in mind most practice acts have provisions for support “extenders” which calls for some level of competency and review of competencies.
6. C but this question would not reach the threshold of psychometric properties since answers would be all over the place and it would have to be tossed out of the test. The number of similar type questions are constantly being asked and debated in clinics and listserv’s throughout the US. What a waste of time. PT’s don’t go to school to figure out some counter-intuitive definition of group therapy.
7. E. All of those are part of the medicare superimposed rules that are breaking the backs of PT’s. We get so used to them that we often think they are part of our practice act. Shame on us. We need to fight for their elimination rather than passively sit back and have CMS keep adding them towards our extinction. We also need to restrain the efforts by many in our profession who are actively promoting CMS as the standard and are pushing for all payors and practice models to adopt them as standard.
8. E. Per CMS’ own language PTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.” Since we know therapist extenders can’t likewise make clinical judgments why don’t they let their work count since they are allowed in almost all state laws?“
9. A. Most practice acts allow for the use of therapist extenders provided they have received training and an annual review of competencies. By disallowing therapist extenders (outpatient only under CMS) they restrict the therapists decision making in delineating what it most cost-effective resource that should provide intervention. 10. B. The National Association for the Support of Long Term Care. Why hasn’t APTA stepped up to plate on this? Perhaps they are too worried about the politics of “taking sides” in an organization that is split on the use of extender issues. My take is they have no guts. A simple and defensible position ought to be “We believe that PT's are fully capable of acting within their scope of license within their state practice acts. In regards to the use of extenders, provided their state practice acts allow for this, we defend a PT’s ability to make clinical judgments for the patient's best concern”. 11.A. This one isn’t even close. More federal and state regulations for health care than any other industry than nuclear power! Think of HIPAA, ADA, OSHA, corporate compliance, etc. etc. As an aside, nuclear power plants have a problem called NIMBY (not in my backyard). Perhaps CMS doesn’t want a PT clinic in your backyard either! 12. D. Hope there is little debate on this one. My assumption is that a room full of academics and practicing PT’s would come to the same conclusion. 13.D. Crazy world we live in. 14. E. Aren’t you glad you went to PT school to learn at least 4 different types of supervision!! 15. E. Lots of speculation, no real explanation. 16.E. PT represents over 75% of all outpatient therapy spending. It makes sense to combine its cap right? Post your grades and your thoughts please. Hopefully many of the question will irritate you and perhaps even convince you to come onboard a grass roots movement to “operation restore PT”. We have let regulators “gone wild” on our profession and need to restore logic and reason to rules and regulations so that we can spend time providing the best in evidence-based care to our patients rather than worry about “line of sight” supervision and determination of “group” therapy.
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