From One “Assistant” To Another….

Montero Therapy’s guest blogger today is – Kerri LaScala, Physical Therapist Assistant. Check out Kerri’s bio here. As always, Kerri has a great perspective and valuable information to share. Even though the Blog title is “From One Assistant To Another,” we encourage all PT’s and OT’s to check it out as the info also involves You!

A few thoughts for my peers…

I’m out in the field with therapist assistants just like you and yes, there are many changes going on in the short term/long term care setting. There also seems to be some confusion as to how “things” in the therapy department should be done. In my travels, I  have heard staff ask questions and share concerns about what we, the “PTA’s” and COTA’s” are being asked to do. It seems every facility does “things” a little bit differently–from how the notes are written, who writes them, how patients are seen, and more. Staff offer reasons as to why this is so, such as “we’ve always done it this way,” or “this is what we learned at a course” or “this is how our rehab company does it,” or “our consultant said this is the correct way.”

So… this is why I am writing today…to open the can of worms, at least partially.

Whose job, whose responsibility,  is it to know what can and cannot be “done?” by Assistants? OURS! We, as registered/licensed professionals, all have a responsibility to educate ourselves on the rules, regulations and LAWS that govern our practice. This includes not only our state practice act, but the federal regulations that govern practice in long term care, Medicare and Medicaid. It is not the physical therapist or occupational therapist that is responsible for knowing and passing on the rules to Assistants. We are responsible for ourselves. With that being said, the PT and OT also must know the rules that govern our practice as Assistants, since we practice under their license.

Listed here are questions I have heard quite a few of you ask when out in the field and I thought I’d share them….as well as the answers and resources behind them. Remember, Federal rules apply to all of us across the country (ie: Medicare) and State laws may differ a bit according to our own State Practice Acts. Different payors (insurance companies) may also have their own specific set of rules of what Assistants can and can’t do–or should I say, what they will/will not reimburse if performed by an Assistant. If some of the rules conflict with each other or overlap, we always need to make sure we are following the most stringent rule.

1. Can a PTA provide a treatment when a PT is not on site in the SNF setting?

• Let’s start with the Federal rule from Medicare. The following is from the Medicare Benefit Policy Manual:

 A physical therapist must supervise PTA’s. The level and frequency of supervision differs by setting (and by state or local law). General supervision (PT not on site but readily available) is required for PTA’s in all settings except private practice (which requires direct supervision-in the office) unless state practice requirements are more stringent, in which case state or local requirements must be followed.

• Next, we have to look at your State Practice Act for the regulations pertaining to the skilled nursing facility. (Remember, each practice setting, i.e. Home Care vs. SNF, can have a different rule in your state as well.) States are likely to be more stringent than Medicare, in which case must be followed. Check your state.

New York, for example, has a more stringent ruling stating that a physical therapist must be on site in a SNF in order for a PTA to provide treatment. So if you are a PTA in NYS, a PT must be on site in order for you to treat. This has nothing to do with Medicare—This is NYS law. New York has one exception to this law which pertains only to residents in a SNF on a Maintenance program. Residents on this type of program, which is a documented maintenance program not covered by insurance, can be treated by a PTA without a PT on site.(This is not to be confused with the “skilled maintenance therapy” that has come up recently, stating that Medicare may reimburse these services-as PTA’s are not permitted to treat this type of maintenance patient under the Medicare ruling anyway)

So, there are really 2 answers for this question for New Yorkers: Yes, a PTA can treat without a PT on site if the patient is on an established maintenance program. However, if the patient is not on a maintenance program and is receiving restorative physical therapy then NO!! STOP!! We cannot provide or bill for a treatment if there is not a PT on site.

2. Can a PTA “co-treat” with another PTA or PT?

No! You cannot “co-treat” within the same discipline. Can a PTA help a PT or another PTA with a patient, yes, but that is not a co-treatment.  A co-treatment is a function of Medicare Part A coverage and is defined as 2 different disciplines treating the same patient at the same time. In this situation, both disciplines can bill the time spent co-treating on the MDS, as long as documentation reflects the co-treatment. So if you need an extra set of hands from your own discipline, you can only bill individual minutes and only the primary treating therapist can bill that time (even if you’re both scheduled to provide a treatment to that patient that day). If it is possible that there are situations out there where a PTA may be co-treating a Medicare Part A patient with another PT or PTA, and both of these therapists are adding their minutes together and including all on the MDS, this is not acceptable practice. Refer to the RAI Manual for more detail on this.

3. Can we round up our treatment minutes?

No! You need to bill the exact treatment minutes spent providing skilled care with the patient, regardless of the payor–Medicare Part A, Part B or an HMO.  In fact, total daily minutes ending in 0 or 5 are subject to audit for this very reason.

4. Do you have to write a daily note for each patient you treat?

The short answer is Yes.  Remember the old saying “if you didn’t write it, then it wasn’t done?” Well, that still applies.

Here is the long answer:

1. Medicare requires a Daily Treatment Encounter Note for reimbursement as per the Medicare Benefit Policy Manual. Quoted from the Manual, “The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service.”
2. Our professional associations describe writing a daily treatment note as a “Standard of Practice.”
3. Insurance companies require documentation on what you did, why you did it and the outcome for each patient.  After all, they are paying for a service you are providing so how else would they know that, #1 You provided the treatment, #2 The patient benefited from it and #3 What will happen next.
4.  It’s helpful for your supervising PT to see your documentation in order to progress the patient as necessary and oversee treatment.
5. What if you’re out sick tomorrow??? How would someone coming in to cover for you know what you were working on and how the patient had been tolerating the treatment.
6. CYA (Remember that?)
7. And if nothing in 1 through 6 has grabbed you…Here’s a biggie…Lack of documentation for treatment may be considered professional misconduct depending on your State Practice Act. Here’s an excerpt from NYS PT Practice act: “Failing to maintain a record for each patient which accurately reflects the evaluation and the treatment of the patient… is considered Unprofessional Conduct under Rule 29 of the Board of Regents

Good documentation is key to a successful and safe therapy experience for you and your patients. In the end, if you are still not sure of something, you can always look to your practice act and state law for guidance on what You, the Assistant, can provide. After all, it’s Your license!!

Helpful Information and Links

For those of you in New York, did you know that you can earn 2 FREE CONTACT HOURS (.2 CEU’s) for taking the “Test Your Knowledge of Law and Practice Quiz” on the Office of the Professions website? Check it out and see how you do…you may be surprised! If you don’t do so well, here’s the link to the Practice Act Q&A page…but we should all read the Laws, Rules & Regulations (it won’t take that long..). For those of you that are not in New York, I encourage you to take a few minutes and search your Office of Professions/Department of Education / State Board and see what it out there.

Other helpful links: APTA, AOTA, Medicare

And remember…….. Montero Therapy Services is always a great RESOURCE too! There are a few things you can do to stay in the loop….Subscribe to this website…It’s FREE and includes links and resources to help you help yourself! Follow us of Facebook/MonteroTherapy and will keep you posted. We are here for You!

Any questions, submit them to our Just Ask! page.