the pmtp phases of care active and passive care prognosis mmi adjusting goals, duration, and...

The PMTP

• Phases of Care • Active and Passive Care• Prognosis• MMI• Adjusting Goals, Duration, and Frequency• Physiotherapy selection

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3-1-06

Care StatusPhase of Healing

Stage of Care

• Phase I Acute Inflammatory• Phase II Repair / Regeneration• Phase III Rehab / Remodeling

Phase I Phase II Phase IIIAcute Regeneration RemodelingInflammation Repair Rehab

Mild 2 days

Moderate 3-4 days

Moderate to severe 7 days

Mild to moderate 6 weeks

Moderately severe up to 16 wks.

Mild 2-3 weeks

Moderate 4-8 weeks

Moderately severe up to

1 yr.

Medicine and Science in Sports and Exercise

Examples of Time frames for mild, moderate, and moderately severe conditions and phases of healing.

Phase I Phase II Phase IIIAcute Repair RemodelingInflammatory Regeneration Rehab

PASSIVE CARE

ACTIVE CARE

decreases

increases

Time / Number of Visits

Passive / Active Care Examples

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Zeroing in on

Prognosis

Prognosis

Prognosis: What your patient can expect. You forecast as to the probable outcome of their condition.

One word descriptions (Good -Poor) are inadequate, offer no explanation as to evidence to support the prognostic conclusion, and are unacceptable.

Prognosis

Arriving at a technically certain prognosis after the initial exam may not be possible especially during the acute phase.

This patient is in the acute phase of care. Prognosis is deferred until the response to the initial therapeutic trial is determined by progress exam in 4 wks

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Prognosis deferralAcute Phase

Prognosis is deferred until the patient’s response to the initial therapeutic trial has been determined by progress examination in approximately 4 weeks.

Good Prognosis Example

• The prognosis is good and is based upon– excellent patient compliance in keeping

appointments (11/12 kept) and performing home therapy

– reduction in pain scores from 6 to 3,– improvement in the NDI from 42% to 18%,– and substantially improved cervical range of

motion.

Fair Prognosis Example

• The prognosis in this case is currently considered fair based upon the following:– There were (4) previous episodes of low back pain

resulting in loss of work time and light duty restrictions over the past 3 years.

– Mild obesity, deconditioning syndrome, and smoking 2 packs of cigarettes / day for past 5 years.

– Pain score improvement from 6/10 to 3/10.– Low back Oswestry score improved from 48% to 30%.– 9/12 appointments kept over the last therapeutic trial

Poor Prognosis Example

• The prognosis in this case is poor in consideration of the following:– Non-compliance with the agreed upon treatment plan,

missing 6/10 appointments.– Non-compliance with the agreed upon home exercise

program.– Obesity and moderately severe de-conditioning

syndrome.– Diabetes and non-compliance with diet and nutritional

recommendations.• Document in SOAP notes

Poor Prognosis Example

• The prognosis in this case is poor due to the following:– Low back Oswestry score is 58% , indicating a

moderately severe patient perception of disability performing routine activities of daily living.

– Moderately severe degenerative disc disease L5/S1 with attendant radiculopathy of the right lower extremity

– Decreased coordination, strength, sensation, and proprioreception of the right lower extremity.

UNACCEPTABLEPROGNOSISEXAMPLE

• The prognosis in this case is good with patient compliance

• The above Prognosis is unacceptable

• MUST ANSWER THE QUESTION: WHY?

Prognosis

• One word prognosis is unacceptable.• Prognosis is good with patient compliance is

unacceptable– ADD THE WORD “BECAUSE”

– THINK OF THE PHRASE “BECAUSE OF THE FOLLOWING”

– …DUE TO THE FOLLOWING FACTORS / OBJECTIVE FINDINGS

– YOU MUST DOCUMENT YOUR REASON(S).

This patient is in the acute phase of care. Prognosis is deferred until the response to the initial therapeutic trial is determined by progress exam in 4 wks

3-1-06

In some cases, if you cannot reasonably forecast the patient’s anticipated response to care (the PROGNOSIS) especially during he acute phase based upon a one time exam, how can one be reasonably certain regarding the date of MMI?

MMIMaximum Medical Improvement

• The patient’s condition is static and stable.• Patient symptoms, your objective exam findings, and

Outcome Assessments show little or no improvement after 2 progress exams..

• When further care does not bring about OBJECTIVE MEASURABLE IMPROVEMENT!

• The patient may then be a candidate for supportive care.

Supportive / Palliative Care

• Treatment rendered after achieving maximum medical / therapeutic benefit.

• Periodic trials of withdrawal from care fail to sustain previous treatment gains.

• Excluded from Medicare coverage. Not considered medically necessary.– Excluded from most insurance policy coverage

MMI DOES NOT MEAN• RELEASING THE PATIENT WITH A PAIN SCORE

OF 0, • OR AN OSWESTRY SCORE OF 0%, • OR WITH NORMAL R.O.M MEASUREMENTS

CONFIRMED BY YOUR INCLINOMETER!

• Maximum Therapeutic Benefit (MMI?): when there are NO DETECTABLE measurable changes (improvements) identified over the course of 2 therapeutic trials as determined by 2 progress exams AND OUTCOME ASSESSMENTS

MMI Uncomplicated Case

• An uncomplicated mild to moderate ankle sprain– 6 WEEKS OF CARE ESTIMATED– OPPORTUNITY TO SEE THE PATIENT

THROUGH THE 3 PHASES OF HEALING– ESTABLISH THE MMI DATE ABOUT 6

WEESK OUT FROM THE BEGINNING CARE.

MMI Date for Complicated Case• Low back pain 6/10, Oswestry score 50%• Moderately severe DDD L5S1 with weakness of the R

LE• Overweight smoker with significant deconditioning• Acute on chronic condition with PMHX of multiple

disabling events, • Compliance to home therapy, nutrition, and in-office

care is fair, keeping 7/10 appts.• Anticipated MMI date 16-24 weeks out from initial care,

pending results of further diagnostic testing, referrals, and measurable change to Outcome Assessments.

Establishing an MMI date

1. Determine if it is a mild, moderate, or moderately severe condition.

2. Are there complicating factors that adversely affect prognosis?

3. Is the patient compliant with home care and keeping appts?

4. It is better to select an MMI date a little further out and releasing the patient early, than to repeatedly miss the mark you select (target date)

DOCUMENT THE PROGNOSIS AND MMI DATE AS SOON AS

REASONABLY POSSIBLE

1. During the initial exam or

2. At the time of the the first progress exam

3. The prognosis may be updated / changed based upon the availability of new information

MMI

• Maximum Medical (Chiropractic) Improvement is determined by the results of all of the components of your examination– Ortho– Neuro– ROM– Strength– Outcome Assessments / effects on ADL

• AS WELL AS HOW YOU SET UP YOU TREATMENT PLAN AND TX GOALS!

Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (739.1) and the lumbar spine at L5 (739.3). Begin Diversified adjusting week 2, after acute pain and spasm have been reduced

3 times per week for 3 weeks

Reduce and stabilize joint dysfunction of the cervical spine at C2 and C5 (7391.) and the lumbar spine at L5 (739.3). Begin Diversified adjusting 2nd week of treatment after acute pain has been reduced and stabilized.


Joint mobilization 971403x week for 1 week

Gently increase intersegmental ROM, pump out inflamm exudates, prepare joints for grade V manipulation / adustment





Ultrasound-pulsed Reduce acute inflamm / swelling 3x week for 1 week97035





Ultrasound Reduce acute inflamm / swelling 3x week for 1 week

EMS- Interferential 97014 High and low frequency for pain modulation and swelling / inflammation, and muscle spasm

3x week for 2 weeks

97035







3x week for 2 weeks

Muscle Spasm

Violent involuntary contraction of muscle attended by pain and interference of function. An ACUTE phenomenon.

Mostly commonly seen the 1st week post trauma, and resolved within a few weeks.

Possibly seen and palpated during an acute on chronic episode.

If muscle spasm is commonly documented during the subacute (repair regeneration) phase and the rehab (remodeling) phase, it lessens the credibility of the provider and may trigger a fraud investigation by 3rd party payors.

Muscle spasms that occur 4, 6, and 10 weeks into the treatment plan would be extremely rare and may require referral, and minimally an advanced neurological examination

97035







3x week for 2 weeks

97014 EMS unattended

97032 EMS attended / manual- applied by the hand of the therapist requiring constant attendance for therapy to take place

97035






EMS- Interferential 97014 High and low frequency for pain modulation and swelling / inflammation nd muscle spasm

3x week for 2 weeks

Soft foam cervical collar.Verbal and written instructions supplied

DATE DATE

Cold pack. Written and verbal instructions supplied

DATE DATE

Intern signature legible!

ALWAYS

7 + 6 + 8 = 21 / 3 = 7 QVAS score






EMS- Interferential 97014 High and low frequency for pain modulation and swelling / inflammation

3x week for 2 weeks


DATE DATE


DATE DATE

7/10 Reduce QVAS from 7 to 5 in 4 weeks (achieve this goal on or before the progress exam

See entire acute care tx plan above

Intern legible signature

My back and neck hurt me more when I try to get in and out of my car

C

2

C

2

F

5

D

3

D

3

D

3

D

3

D

3

C

2

D

3

Intern legible signature

My back and neck hurt me more when I try to get in and out of my car

C

2

C

2

F

5

D

3

D

3

D

3

D

3

D

3

C

2

D

3

27 pts X 2= 54

54% Oswestry Disability Score

Joint mobilization97140

3x week for 1 week



EMS- Interferential97014

High and low frequency for pain modulation and swelling / inflammation

3x week for 2 weeks


DATE

DATE


DATE

DATE

7/10Reduce QVAS from 7 to 5 in 4 weeks (achieve this goal on or before the progress exam


Oswestry Low Back Disability Score

DATE

54% Improve patient comfort and safety transfer in and out of their car

ADL training 97535 1x per week for 2 weeks

97035

Legible intern signature

DATE ALWAYS

Legible intern signature

DATE ALWAYS

28 pts X 2 = 56% NDI score


3x week for 1 week





3x week for 2 weeks


DATE

DATE


DATE

DATE




DATE



97035

Neck Disability Index 56%

There are a lot of Activities of Daily Living issues with this case as documented by the Oswestry and NDI. In the ACUTE phase, it is better to focus on helping them with the reachable and critical necessities

•Self care

•Driving – transfer in and out of vehicle

•Sitting- getting in and out of chair

Recreational activities and lifting heavier objects are examples that may be addressed in later phases with active care / rehab.

currently

Goal to achieve by progress exam date


3x week for 1 week





3x week for 2 weeks


DATE

DATE


DATE

DATE




DATE



97035

Neck Disability Index 56% To look after herself normally despite pain by the next progress exam

ADL Training-verbalize and demonstrate ability to perform

975351x and re-evaluate in 1 week. See SOAP notes for additional ADL info.

Acute Inflammatory Phase• Activity restrictions / work restrictions

– Based upon exam findings, outcome assessments, job description etc.

• Short term immobilization and bracing– Collar, belt, rest

• Reduce inflammation and pain– Home therapy– Physiotherapy– Nutritional intervention

• Document advice / ADL instructions• Adjusting vs. mobilization (joint motion w/o thrust)

PMTP Example Phase II Repair- Regeneration

PMTP Example

• Repair Regeneration Phase II • Low back patient

– Prognosis– Adjusting goals– Outcome Assessments

• Treatment plan• Treatment goals

Intern signature legible!

ALWAYS

4 + 4 + 7 = 15 / 3 = 5 QVAS score

Legible signature

40% Oswestry Score

2

1

4

2

2

2

1

3

1

2

My back hurts more and feels weak when I lift and care for my 2 y/o baby

Prognosis to date is good based upon excellent compliance to the treatment plan, approx 50% improvement in ROM, fewer + orthopedic tests, reduction in pain , Oswestry, and Neck Disability Index scores.

Biomechanical and structural pathology from Rad report goes here. Will this info affect the prognosis? Are any of these findings worthy of making it up to the Diagnosis section

Prognosis to date is good based upon excellent compliance to the treatment plan, approx 50% improvement in ROM, fewer + orthopedic tests, reduction in pain , Oswestry, and Neck Disability Index scores.

Biomechanical and structural pathology from Rad report goes here. Will this info affect the prognosis? Are any of these findings worthy of making it up to the Diagnosis section

CVA/ cardiovascular risk

Safety issues collected from outcome assessment data.

Work / recreational issues – re-injury / joint protection

Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4.

3x week for 4 weeks

Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4.

3x week for 4 weeks

EMS - Interferential 97014 3x week for 2 weeksFor pain control

Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4. Increase intersegmental and global ROM per clinical exam and inclinometry ROM testing

3x week for 4 weeks

EMS - Interferential 97014 3x week for 2 weeksFor pain controlTherapeutic exercises 97110 Increase ROM and, strength 2x week for 4 weeks

If your examination documents loss of strength, endurance, range of

motion, or flexibility, the selection and performance of 97110 may be

considered medically (chiropractically) necessary.

It would not be appropriate to select 97110 to decrease pain.

97110 therapeutic exercises to develop strength and endurance, range of motion and flexibility, one or more areas, each 15 minutes

Reduce moderately severe alterations in joint endplay hypomobility (739.3) at L4. Increase intersegmental and global ROM per clinical exam and inclinometry ROM testing

3x week for 4 weeks


5 Reduce QVAS score to 3. Decrease pain at its worst from 7 to 5 in 4 wks.

EMS – Interferential

Therapeutic exercises 97110 Increase ROM, flexibility, strength 2x week for 4 weeks

97014 3x week for 2 weeks

Legible signature

40% Oswestry Score

2

1

4

2

2

2

1

3

1

2

My back hurts more and feels weak when I lift and care for my 2 y/o baby


5 Reduce QVAS score to 3. Decrease pain at its worst from 7 to 5 in 4 wks.

Therapeutic exercises 97110 Increase ROM, flexibility, strength 2x week for 4 weeks

Oswestry Score 40%The pt. will demonstrate the ability to safely lift her 2 y/o baby using proper mechanics and joint protection


Legible signature

ADL

Issues

*Lifting

*Walking

*Standing

Don’t Ignore Documented ADL issues

• It would be appropriate to address some of these ADL issues during Phase II Repair Regeneration Phase of Care / Healing– Walking– Standing – Lifting?

Oswestry Score 40%The pt. will demonstrate the ability to safely lift her 2 y/o baby using proper mechanics and joint protection


Oswestry Low Back Score 40%

Improve walking and standing tolerances (endurance). NOTE: LIFTING HEAVIER WEIGHTS MAY BE AN INNAPROPRIATE GOAL DURING PHASE II HEALING AND CAUSE FURTHER INJURY. PHASE II SHOULD BE PREPARATION FOR MORE AGGRESSIVE EXERCISE IN PHASE III

Therapeutic exercises 97110 2x week for 4 weeks

Improve walking and standing tolerances (endurance). Demonstrate ability to lift 1.5 x the weight of her baby from the floor and various elevations up to waist level.

Phase II Repair Regeneration Phase• Adjustments• Physiotherapy

– EMS– Microcurrent– Traction– Soft tissue work – ischemic compression

• Therapeutic exercises– Home therapy / stretches– ROM exercises, isometrics– ADL activity improvements

• This phase represents a combination of passive and active care.

Phase III Rehab Remodeling

PMTP Example

• Rehab / Remodeling Phase Example– Prognosis

– Adjusting goals

– Outcome Assessments• Treatment plan• Treatment goals

PMTP Example• Areas involved: Lumbar spine

• Severity: Mild to Moderate

• Outcome Assessments– QVAS (Quadruple Visual Analog Scale)– Oswestry (Low back)

Prognosis is good based upon a 50% improvement in the pain score and Oswestry score the past 4 weeks. ROM has improved in all planes except lumbar extension. Lumbar neural tension signs are negative. This patient is ready for an aggressive rehab / conditioning program.

Cervical spine joint dysfunction (739.1) has resolved. Continue CMT to lumbar spine level L5 (739.3) to improve intersegmental ROM and reduce the 2mm retrolisthesis at this level.

1x week for 4 wks


1x week for 4 wks

Therapeutic exercises 97110 Develop strength, ROM and flexibility 3x week for 4 wks


3

1x week for 4 wks

Improve pain at its worst from a 6 to a 3

CMT-Adjustment 98940 1x week for 4 weeks

Therapeutic exercises 97110 Develop strength, ROM and flexibility

Legible signature32% Oswestry

1

0

4

2

3

2

1

1

1

1

It is common for OT’s and PT’s to select the next letter or two up as a target goal to achieve by the next progress exam

3 Improve pain at its worst from a 6 to a 3

Oswestry Score 32% Improve to lifting heavier objects that are conveniently positioned. Improve walking tolerance to ½ mile or 20 mins; improve sitting tolerance to 1 hour

Therapeutic exercises 97110 3x week for 4 weeks. Gradually increase exercise time to 30 minutes. See SOAP notes for addtl data

?

For post workout soreness, home stretches etc?

CMT - adjusting 98940 1x week for 4 weeks

Phase III Rehab Remodeling Phase

• Adjustments less frequent. Generally not in the 3x week mode.

• Minimal to no physiotherapy modalities • Active care:

• ROM exercises, stretches• Weight machines• Tubing exercises, exercise ball• Balance boards, proprioreception,• Treadmill, exercise bike, upper body ergonometer

Phase I Phase II Phase IIIAcute Repair RemodelingInflammatory Regeneration Rehab

PASSIVE CARE

ACTIVE CARE

decreases

increases

Acute on Chronic

• Reduce and stabilize the acute episode

• Move the patient through the phases of care / healing.

• Get them to the rehab phase as quickly as possible, not jeopardizing pt. health, joint integrity, or cause further re-injury.

Clinic Fee Update Examples

• 98940 CMT 1-2 areas $10 $20

• 98941 CMT 3-4 areas $12 $23

• 98942 CMT 5-6 areas $13 $26

• 98943 CMT extraspinal $10 $16

Police

Fire

Active Duty


• Therapy– 97010 hot pack / cold pack $7 $10– 97012 posture pump / wedge $7 $10– 97014 muscle stim unattended $7 $10– 97032 muscle stim attended $7 $10– 97035 ultrasound $7 $13– 97140

• Myofascial trigger point $7 $13• Percussor $7 $13

–


• Active Therapy– 97110 therapeutic exercise $7

$15– 97112 neuromuscular re-ed. $7 $15– 97535 ADL / self care $7 $15

ROF Visit

• The ROF is typically performed on the 2nd or possibly in some cases the 3rd visit.

• Performing a Report of Findings on the initial visit may be possible and advisable in rare cases, and would represent the exception, not the rule.

Clinic Fee Update• 99213 E/M code for Report of Findings

– To be used if the ROF is performed on the 2nd or 3rd visit– SOAP notes must be documented thoroughly

• Total time spent. Begin time and end time• What was discussed?

– Hx, CC, exam, x-ray, restrictions, nutrition, exercise, DX, prognosis

• Document patients questions and concerns• Acceptance of tx plan

– A one line sentence indicating that a ROF was performed is inadequate documentation and will no longer be accepted. Credit will not be approved for that visit unless the ROF visit is thoroughly documented.

Report of Findings Visit

– SOAP notes must be documented thoroughly • Total time spent. Begin time and end time• What was discussed?

– Hx, CC, exam, x-ray, restrictions, nutrition, exercise, DX, prognosis

• Document patients questions and concerns• Acceptance of tx plan

– A one line sentence indicating that a ROF was performed is inadequate documentation and will no longer be accepted. Credit will not be approved for that visit.

Clinic UpdateDr. Thomas

• Professional Behavior

• Physical Contact– Clinic Staff– Patients

the pmtp phases of care active and passive care prognosis mmi adjusting goals, duration, and...

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