In the area of pediatric physical therapy we frequently receive medical referrals for children who have a known medical diagnosis such as Down Syndrome.  While the medical diagnosis may be useful in helping us to be aware of some of the characteristics or relevant conditions we may expect, the diagnosis itself does not dictate what we as therapists may need to address in the treatment of the child.  It is the responsibility of the physical therapist to evaluate the child and determine if there is a condition or ‘treatment diagnosis’ which would benefit from physical therapy treatment.  Determining the needs of the child and the goals you hope to achieve through intervention will help you determine what disorder(s) you will actually be addressing in your treatment. 

By determining a treatable condition, you may be able to circumvent the issues regarding congenital disorders and rehabilitation versus habilitation.  You might consider the example of an adult with Down Syndrome who walks into a PT clinic with shoulder bursitis.  In this case, you would expect the treatment provided was billed with a diagnosis code of shoulder bursitis and not Down Syndrome.  This condition will likely be acceptable for medical reimbursement.

With that in mind, also understand that what insurance companies accept as a diagnosis can change over time.  Many are private companies and do have a right to define their plans.  We need to be alert to changes and adapt.  There are still some insurance agencies including some state Medicaid programs which will allow ‘Down Syndrome’ as a treatment diagnosis.  But, as you can see, some and probably many other agencies are expecting more specificity with regard to what is a reimbursable condition. 

There are online websites which provide free access to diagnosis (ICD-9) codes.   Become familiar with codes which could be classified as treatment disorders.  They include ‘generalized muscle weakness’, ‘abnormality of gait’, ‘lack of coordination’, ‘symptoms involving the musculoskeletal and nervous system’, difficulty walking’ and other conditions which may more closely reflect what you are actually treating.  These conditions still appear general when compared to ‘shoulder bursitis”, but your evaluation will more specifically define the aspect of the condition you are treating and how treatment will improve the condition. 

You have help available in your relationship with insurance companies and reimbursement.  Your state’s Department of Regulatory Agencies should have a Division of Insurance.  It is the role of that office to review unfair practices and negotiate with insurance companies to cover services which are in the best interest of the community.  Some states have established regulations which require health insurance to cover therapies for congenital disorders through a certain age.  In these cases, the insurance companies have no choice but to cover the service, regardless of the defined plan.

In the area of pediatric physical therapy we sometimes receive referrals for children who have a known progressive disorder such as muscular dystrophy.  While the medical diagnosis may be useful in helping us to be aware of some of the characteristics or relevant conditions we may expect, the diagnosis itself does not dictate what we as therapists may need to address in the treatment of the child.  It is the responsibility of the physical therapist to evaluate the child and determine if there is a condition which would benefit from physical therapy.  Determining the needs of the child and the goals you hope to achieve through intervention will help you determine what disorder(s) you will actually be addressing in your treatment.  

When you determine a treatable condition, you reduce the likelihood that your services will be denied because of the patient’s medical diagnosis.  You might consider the example of an adult with cancer who walks into a PT clinic with shoulder bursitis.  In this case, you would expect the treatment provided was billed with a diagnosis of shoulder bursitis and not cancer.  Shoulder bursitis is condition which will likely be improved with physical therapy. Whereas if you were to bill your services for the treatment of cancer it would be denied as physical therapy is not a reasonable treatment for cancer.

With that in mind, also understand that what insurance companies accept as a diagnosis can change over time.  Many are private companies and do have a right to define their plans.  We need to be alert to changes and adapt.  There are still some insurance agencies including some state Medicaid programs which will allow Muscular Dystrophy as a treatment diagnosis.  But, some and probably many other agencies are expecting more specificity with regard to what you are actually treating. Furthermore, Muscular Dystrophy is not the actual disorder you are treating, although the diagnosis has likely contributed to the disorder you are treating.  

Pediatric physical therapists typically treat disorders such as generalized muscle weakness, abnormality of gait, difficulty walking, lack of coordination, abnormal posture, hemiplegia, torticollis and other conditions which benefit from physical therapy intervention.  When billing, you can include the medical diagnosis, such as Muscular Dystrophy on the bill. But your treatments should be paired with the actual condition your treatment is addressing. 

Documentation is the key to success on this issue.  The following is a response from the North Carolina Medicaid program.

From a strictly technical perspective, the documentation submitted should be objective and measurable.  Clinically, the documentation should reflect the role of and need for skilled PT in the patient’s care.  For a child with a progressive neurological or musculoskeletal diagnosis, the role of therapy services may change as the disease progresses and with subsequent episodes of care.  The concept of an “episode of care” is important in determining medical necessity of skilled therapy services.  An episode of care may correlate with symptomatic progression of the disease, growth related changes, medical or surgical interventions, or changes in circumstance, to name a few.  As the disease progresses, the role of therapy may vary; initially, rehabilitative gains may be targeted, but the progressive nature of the disease may warrant a change in focus to compensation and/or adaptation.  Based on the advancement of impairments and the child’s response to therapy services, the therapist would be responsible for determining changes in expectations and the role of continued therapy.

During the “rehabilitation and compensation” phases, the goals and progress towards them would ideally reflect improvement in functional abilities.  As the plan of care changes its focus to one of adaptation, the deficits and goals, and the frequency of visits, should reflect the skilled intervention needed, which would be differentiated from routine services provided by trained caregivers.  The frequency of therapy visits would depend on the rate of progression of the disease process and the varying needs of the client.  The skill of the physical therapist would be warranted in identifying the areas to be addressed via a home program and providing the necessary training to caregivers, and in completing an assessment for necessary equipment and providing training to use equipment safely and effectively.  There are times when an increase in frequency may be warranted, e.g., to address an acute or more dramatic change in status, and there are times when no therapy services would be warranted, e.g., upon meeting equipment needs or when the manifestation of the disease process is relatively stable and an appropriate home program is in place.  Periodic re-evaluations may be appropriate.

Often, questions regarding medical necessity stem from the frequency of visits requested.  It is important that the documentation clearly supports the need for “skilled” intervention.  This may be accomplished by clarifying the following:

• The intervention provided and why the service is not provided by trained caregivers.  Documentation should include equipment, programs and caregiver training that is in place to address the goals and outcome for the patient.  Often, services that are initiated as part of a skilled program can be transitioned to caregivers and incorporated into routine daily care.  For example, if there is a concern about losing range of motion, caregivers can be instructed to perform range of motion activities daily or throughout the day; this could be more effective than periodic therapy visits to correct or ameliorate the impairment.      
• The intervention provided, and why it couldn’t be done at a lower frequency.  For example, specify what, if any, changes are noted between regularly scheduled visits and when PT visits are missed.  Missed visits or a gradual reduction in the frequency of visits can be a useful means of supporting the need for a higher or lower frequency of visits.
• Barriers to achieving goals.  Support for PT and OT services can be boosted by specifying barriers and distinguishing those that can be overcome from those which can not be controlled.

It is not necessary to write a detailed progress report with every treatment note. It is useful to distinguish between a treatment note and a progress report.  These should be completely different documents.  Consider treatment notes as a summary of what you did. (Proof that you provided the treatment). Pediatric treatment notes might say:  'worked on trunk strength, balance, coordination', or 'focused on foot placement, single leg stance, weight shifts', or 'worked on floor to sit transitions with UE weight bearing' and always include time spent.  Try to keep it brief, because the only point of treatment notes is to allow the insurance company to verify that you provided the treatment billed.  It is useful to refer to treatment goals in your treatment notes.

A progress report is a separate, less frequent and more detailed document. An evaluation or progress report is used by insurance companies to determine if the service provided is medically necessary, but the people who review those reports do not typically concern themselves with the day to day billing.  So you can provide progress reports at the frequency requested by the insurance company or when goals need to be updated. This doesn't mean you don't acknowledge progress in your treatment notes:  'took 12 steps unsupported', or 'beginning to pull to stand', but you can save the details for your progress report at a later date.

Although the Federal Government has regulations and funding for State Medicaid programs, it is up to each state to interpret and implement this program. In fact, physical therapy is an optional covered service under Medicaid.  This creates huge variances in Medicaid physical therapy service rules and regulations across the country.  For this reason, this problem needs to be addressed at a state level. 

The Section on Pediatrics website has a link called “Reimbursement Contacts by State” see http://www.pediatricapta.org/members/peds-govt-affairs.cfm and look at the information posted for your state.  Your state chapter has a reimbursement representative or committee.  Additionally your Pediatric Section State Representative may be of assistance as well as other listed contacts.   The Government Affairs office at APTA can also be of assistance with regard to policy issues at times. 

We all agree the premise for provision of therapy differs between school and outpatient facilities...

Given this, the outpatient therapy should be covered if the therapist can document collaboration with the school therapist clarifying that "duplication" is not occurring, and that other goals are being addressed. If Medicaid is being billed for therapy by both school and OP service, this becomes especially important. Sometimes it may be a matter of switching gears (example OP provider provides serial casting, which is not able to be provided in the school, then the school takes over)

In Georgia, for instance, Medicaid won't pay for hospital based OP services, but will pay for "CIS" providers ( chronic intervention service providers), in addition to school consults, provided the collaboration piece is present.

Sometimes, you have to document the presence (or absence) of an IEP, and request a copy of the same. You must be careful not to document the same goals. This must also sometimes be done for kids receiving therapy paid by private insurance who receive therapy at school as well. This additional work (getting the IEP goals, handling the releases etc. ), is a pain, BUT, in the long run improves communication and outcomes in the sense that all providers are informed/ on the same page.

The dialogue with your state Medicaid program is important and Medicaid should be pressured not to deny services outright. It is also sometimes helpful to get elected officials involved.  The ‘don't ask don't tell’ policy must be discouraged however, because it does not solve the problem, and in the end someone is paying for services, possibly twice over. Moreover there is an element of underhandedness that does not sit well on pediatric professionals.

Even though a child may not be formally diagnosed, as a physical therapist you should indicate the disorder you are treating.  There are really a lot of options.  There are several websites with free access to ICD-9 codes and it is very interesting to browse. 

You can try treatment diagnoses such as : Coordination/hypotonia (781.3) or generalized muscle weakness (728.87) - if weakness is a constraining factor preventing developmental motor progress. Also figure out the specific functional issues e.g. is there difficulty walking? - there are specific diagnostic codes for functional problems too.  Many insurance companies do not cover codes with ‘developmental delay’ in the definition as they consider this a problem that will correct itself.  You need to determine the underlying condition for the problem and why this child needs PT.

Restrictions for allowable time for equipment are usually just guidelines (geared toward adults) and not hard and fast rules.  If there is a clear need for a change in equipment due to the patient’s change in function or growth of a child, the equipment will usually be allowed.  A letter of justification reflecting medical need is usually very powerful.

Physical therapists have the perspective that can explain the need for mobility and positioning equipment.  If the child’s plan has an exclusion plan with strict time frames, the family may need to look for other resources for payment and consider getting a different health care plan in the future.