CPM Provider Newsletter Digest

CPTB Set to Discipline PTs 4

PT, Inc 5

Coding, Cloning, Template Notes

7

Decisions to Avoid Penalties 8

Volume 8, Issue 11

P hysical therapy chart notes are an important part of the dai ly responsibilities that a

therapist must complete. Chart notes are how therapists document their patient treatment sessions.

Most Physical Therapy notes are written in the S.O.A.P note format, which stands for Subjective, Objective, Assessment and Plan. It is a record of the progress of the patient, which is included in his or her patient chart.

Good documentation enables therapists to provide optimal treatment services to patients. They are also required for therapists to receive reimbursements from third party payers. More and more payers are denying claims for improper and/or illegible documentation

SOAP notes are found in every

patient chart and can be completed through a variety of methods with the most traditional being the handwritten note.

However, with advancements in technology, SOAP notes have shifted to electronic methods allowing therapists to complete documentation more efficiently.

Applicable for both hand written and electronic documentation systems, the following guidelines are intended to be used as a foundation for the development of more specific documentation guidelines in clinical areas across all practice settings.

Documentation may also need to address additional regulatory or payer requirements.

Continued on pg 2

W hen determining the medical necessity of the item or service bi l led, Medicare's

review contractors must rely on the medical documentation submitted by the provider in support of a given claim. Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials. Continued on page 3

CPM Provider Newsletter Digest

INSIDE THIS ISSUE:

November 2012

"Character is frequently judged by handwriting. Write a good, clear,

legible hand, without any flourishes, and always use the best and the blackest of ink." 1800’s wisdom

Geographic payment adjustments: Medicare’s disputed borders, pg 9

Special PT SOAP Note Abbreviation Section,

pg 13

A more proper/functional SOAP note format would be:

Subjective The information contained in the subjective part of the PT note includes what the patient says about his or her condition or problem. It can be in the form of a quote from the patient's statement, for example, "My back is so painful, especially after sitting for many hours at work."

It is better to look for subjective information that is more specific, such as "My back pain has reduced from 10 to 6." Or it can be stated as "Patient states that his back pain has reduced from pain level of 10 to 6."

It is important that in this section, the subjective information should be related to the patient's condition, progress in rehabilitation, functional mobility or quality of life. Other irrelevant information should be excluded, such as "Brittney's bald again." Objective This section of the PT note is where concrete measurements, such as blood pressure and range of motion and treatment interventions performed are recorded. This section should include specific treatments. It should also include the frequency, duration and equipment used. The objective section should be specific enough so

that in case the therapist is not available, another therapist can treat the patient. Example: VS: BP = 120/80 mmHg RR = 12 cpm PR = 80 bpm To = 37o Treatments provided: 1) Hot pack on lumbar area x 20 min. in prone. 2) Deep kneading massage on lumbar paraspinal

muscles x 5 min. in prone. 3) Ice pack on lumbar area x 20 min. in prone. 4) Prone lumbar extensions x 20 reps. 5) Educated patient on: a. Proper lifting techniques with 10 lb. box lift x 20 reps. b. Proper sleeping techniques with emphasis on maintaining normal lumbar curve. Assessment This is where the impression of the physical therapist is recorded regarding the patient's performance during the treatment procedure. "The patient tolerated the treatment well" statement is commonly used, but it's not telling whether or not the client is progressing throughout the overall treatment plan. Continued...

Let us now break down the basic parts and format of a typical SOAP note that is recommended by the Physical Therapy Board of California and the American Physical Therapist Association.

First, let’s look at a poorly written SOAP note: S = Feel better. O = Hot packs, TENS, US, Massage, Stretching A = Tolerated well. P = Continue

November 2012 CPM Provider Newsletter

From Page 1

Writing physical therapy SOAP notes is an invaluable documentation every physical therapy student should learn. Students learning how to write SOAP notes also need to learn how to write physical therapy abbreviations. We have showcased some of the more common physical therapy abbreviations below. Example of Plan SOAP note: “Continue with current treatment plan. Caution – patient needs frequent verbal cuing with proper lifting techniques. “

Key Points: General Principles of Medical Record Documentation

Be Aware that the general principles of medical record documentation to support a service or supply billed for Medicare payment includes the following:

1. Medical records should be complete and legible

2. Medical records should include the legible identity of the provider and the date of service

This includes the signature of the providing practitioner. If the signature is illegible, the practitioner runs the risk of denial of claims submitted with the illegible signature(s).

Example: “Patient tolerated treatment well and appears to be compliant with home exercise program.” Plan This is the final section of the physical therapy note. It is where the physical therapists would outline the course of treatment after considering the information he or she has gathered during the treatment session. If the therapist would like to continue treatment following the original plan of the care, the PT might just say "Continue with current plan."


From Page 2

From Page 1

to the list of healing art practitioners who may be shareholders, officers, directors, or professional employees of medical, podiatric or chiropractic corporations. The California Physical Therapy Association strongly opposed AB 783 because the legislation would have made it legal for medical, podiatric and chiropractic corporations to employ physical therapists. In effect, under this legislation, these corporations could control the point of access to physical therapist services and then refer patients only to themselves. This type of arrangement poses an inherent conflict of interest and removes choice for the consumer. On June 27, 2011 the members of the Senate Business Professions and Economic Development Committee understood the potential conflict and did not pass the bill. Then in October 2011, Governor Brown signed into law SB 543 which bars the Physical Therapy Board of California (PTBC) from enforcing such an unprofessional conduct violation until 2013 (when the law expires). This means that beginning in 2013, the PTBC

may commence enforcing the law against physical therapists who are employees of medical corporations. The opinion from Legislative Counsel confirms that, because the California Corporations Code does not specifically include physical therapists on the list of those who may be employed by a medical corporation, a physical therapist is prohibited from providing physical therapy services as an employee of a medical corporation and may be subject to discipline for “unprofessional conduct” under the Physical Therapy Practice Act, by the Physical Therapy Board of California. The Department of Consumer Affairs agreed with this in a legal opinion dated February 28, 2011. This enforcement begins January 1, 2013.

T he existing California Corporations Code does not specifically include physical therapists on the list of those who may be shareholders, officers, directors, or professional employees of medical, podiatric or

chiropractic corporations. In 2011, Assembly Bill 783 was brought forward by the California Medical Association to determine the legality of physicians owning a physical therapy practice. They were later joined by the California Orthopaedic Association and California Chiropractic Association. AB 783 would have amended Section 2406 of the Business and Professions Code and Section 13401.5 of the Corporations Code to add licensed physical therapists


therapist to own a corporation may have been an illegal “underground regulation.”Accordingly, since that time, the proper corporate organization for a physical therapist is a physical therapy professional corporation whose shareholders, officers and directors are physical therapists. Non-physical therapists cannot own shares of a physical therapy professional corporation.

Physical Therapist Employees of a Medical Corporation – Another legal issue surfaced in 2010 regarding whether or not a physical therapist may lawfully work as an employee of a medical corporation. After legislation regarding this issue was defeated in 2009, the Legislative Counsel Bureau issued a legal opinion stating that medical corporations could not legally employ a physical therapist and that such employment could constitute “unprofessional conduct” under the Physical Therapy Practice Act. The Department of Consumer Affairs agreed in a legal opinion dated February 28, 2011.

Then in October 2011, Governor Brown signed into law SB 543 which bars the PTBC from enforcing such an unprofessional conduct violation until 2013 (when the law expires). This means that in 2013, the PTBC may commence enforcing the law against physical therapists who are employees of medical corporations.

Possible Organizations of Physical Therapy Practices

Like a number of other businesses, physical therapists can organize as a sole proprietor, a partnership or a professional corporation. A sole proprietorship is the least formal arrangement involving a single owner, but offers little structure or formality and no protection from liability for its owner. A partnership is similar to a sole proprietorship, but each partner shares equal responsibility for the company’s profits and losses, debts, and liabilities depending on how the partnership ownership is defined. A practice operated as a partnership offers no protection for the owner’s personal assets. The partnership itself does not pay income taxes, but each partner has to report their share of business profits or losses on their individual tax return. Estimated tax payments are also necessary for each partner for the year in progress.

Even in spite of the regulatory issues described above, a physical therapy professional corporation is the best option for a growing physical therapy practice that wants to protect the owner’s assets and will benefit from the formality of a corporation.

Continued...

T here have been recent regulatory and legislative changes for physical therapists in regard to corporations and Medical Corporations that employ physical therapists.

As explained on the Physical Therapy Board of California (PTBC) website, there have been two significant issues pertaining to physical therapists in a corporate environment.

Physical Therapy Corporations — On November 30, 2010, the PTBC rescinded its 1990 resolution titled “Physical Therapy Corporation Ownership by a Layperson.” the PTBC determined that its 1990 resolution which authorized a non-physical

CPM Provider Newsletter November 2012

P.T., Inc

shareholders, officers and directors. Whether rewarding excellent employees – physical therapist employees, mind you – with the opportunity to buy into the practice or selling shares to a purchaser, a corporation offers flexibility in planning for the future.

• Tax benefits/deductions – There can be tax benefits for incorporation. There can be significant deductions that may be available to corporations that are not available to sole proprietors and partnerships. Please consult your accountant or tax professional regarding how these tax benefits will work for you.

• Professionalism/formality – Because the corporation is a separate “person” or entity under the law, it becomes the employer, party to all contracts, marketing entity, etc. In addition to asset protection and tax issues, patients and others will see that you have taken the time to formalize your business and take it to the next level.

• Independent Contractor Status – In many cases where a physical therapist contracts to provide services to medical groups, rehabilitation facilities and others who need physical therapy services, the physical therapist reduces the risk of being reclassified under the law as an “employee” in lieu of an

independent contractor if the contract is between the professional corporation and for example, the medical group. This issue is becoming much more significant in light of the current regulatory environment which includes severe penalties for misuse or misclassification of independent contractors.

While incorporating a practice involves a legal process, the resulting benefits are apparent and often very worthwhile. Once created, the physical therapist must continue to maintain the corporation and observe corporate formalities required by law. Of course we recommend consulting legal counsel regarding how a physical therapy professional corporation will benefit your practice.

Main Benefits of Physical Therapy Professional Corporation

The main benefits of incorporating include:

• Asset protection – The assets of the shareholders of the corporation may be shielded from corporate debts, lawsuits and other liabilities. While an individual therapist may still be liable for his or her own malpractice, protecting the owner’s individual assets from liabilities created by employees or other therapists is a significant benefit of incorporation.

• Business Transition - In the event of death, incapacity or retirement of the physical therapist, a professional corporation allows other physical therapists to serve as


P.T., Inc

From pg 5

truly meaningful documentation. In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits. This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, providers have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those providers who bill higher-level codes.

Some experts blame a substantial share of the higher payments on the increasingly widespread use of electronic health record systems. Some of these programs can automatically generate detailed patient histories, or allow providers to cut and paste the same examination or treatment findings for multiple patients — a practice called cloning — with the click of a button or the swipe of a finger on an iPad, making it appear that the physicians conducted more thorough exams or treatment than, perhaps, they did. One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.

P roviders beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent

New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, template notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to


The American Academy of Family Physicians estimates that participating in these initiatives next year could save a provider $19,000 in avoided penalties. Successfully reporting quality measures and in 2013 will prevent a provider’s Medicare rates from being reduced by 3.5% in 2015 for noncompliance.

“It might not seem like that much money now, but what if it goes up to 5%, 10% or 20%?” asked Bruce Bagley, MD, AAFP’s medical director for quality improvement. “Is it still optional? And what if commercial payers start to do it, too? It’s only going to get harder, so the sooner you get your feet wet, the better.”

The Centers for Medicare & Medicaid Services (CMS) has developed a plan for how penalties will be levied on providers. In general, the agency will apply pay reductions one or two years after the reporting year for the initiatives. An interactive American Medical News questionnaire can help providers determine if they’re headed for steep reductions in Medicare pay in 2014 and 2015 based on their reporting activity in 2013.

Payment adjustments for quality reporting Eligible professionals who do not successfully participate in the physician quality reporting system (PQRS) in 2013 will see their Medicare pay reduced by 1.5% in 2015.

Providers have a couple of options to report to the

Medicare agency from among the PQRS measures. Reporting measures group(s) through the registry option is presented as the easiest method for a provider to prevent a penalty and earn a bonus. CMS will provide a list of active registries in early 2013 — most of which will have been part of the program in 2012.

A registry will require providers to select a measures group, such as diabetes, and use the registry application to report data for at least 20 patients. “The whole project will take you 2½ hours,” Dr. Bagley said. “It’s not the big hurdle everyone thinks it is.”

Reporting individual measures or measures groups using Medicare claims or an EHR also are options for provider practices. Providers will receive a bonus equal to 0.5% of their 2013 Medicare pay if they participate in PQRS.

Failure to report PQRS measures successfully in 2013 will lead to a Medicare penalty of 1.5% on 2015 rates. The reduction will be 2% in 2016 and each subsequent year. For now, CMS is planning to use a PQRS reporting period well before the authorized penalty year to determine who will see their Medicare pay reduced.

Continued...

A physician’s decision not to report Medicare quality measures or participate in paperless prescribing and health record programs in 2013 will be a costly one in the long run.

The programs have been voluntary for the past several years. However, federal laws require Medicare rates eventually to be reduced for physicians who do not participate in the physician quality reporting system as well as the electronic health records and e-prescribing incentive programs. The reason why 2013 is such a critical year for doctors is that Medicare officials are using it as a benchmark for future penalties in all of these programs.


P roviders practicing in all parts of the country long have agreed that Medicare payments have been too low for too long, but a growing chorus

of health policy officials say these doctors’ rates also are inaccurate when compared with one another.

Medicare uses geographic adjustments to pay more in areas deemed to have higher costs of providing care to seniors. The Centers for Medicare & Medicaid Services employs a patchwork of 89 pay locales to set rates in a budget-neutral environment. As a result, a doctor treating a Medicare patient in midtown Manhattan receives more than a doctor providing the same service in rural West Virginia.

In some places, large geographic swaths are considered part of the same region, meaning all doctors in an immediate area receive the same adjustments to their pay. But in other places, the practice just down the road — where building rents, equipment costs and staff salaries are practically the same — could get higher pay for providing the exact same service.

In many areas, the gradations of pay based on geography are relatively slight, and for the most part the factor does not appear to register highly with physicians considering their financial situations.

Physicians in relatively high-cost Maryland, for instance, can practice in one of three payment jurisdictions. Gene Ransom III, CEO of MedChi, the Maryland State Medical Society, said he’s unaware of any physician choosing a practice based on the Medicare adjustment for that location. “All I hear is raising the tide for all boats,” he said.

But physician focus on the bigger picture of pay rates is separate from the fact that states have outgrown the Medicare geographic boundaries established years ago. In Georgia, for example, population has grown significantly in the Atlanta area and in northern parts of the state, said Donald J. Palmisano Jr., the Medical Assn. of Georgia’s executive director and CEO. Georgia doctors, however, are put into one of only two pay jurisdictions: one centered around Atlanta and one composed of the rest of the state.

Continued...

“We urge solo providers in smaller groups to participate in the PQRS now, because when we propose in future rulemaking to apply the value-based payment modifier to smaller groups and solo practitioners, we anticipate basing the quality composite on PQRS quality data reported by such providers,” the agency said. “We also anticipate that we would propose to increase the amount of payment at risk under the value-based payment modifier as we gain additional experience with the methodologies used to assess the quality of care furnished, and the cost of care, by providers and groups of providers.

Doctors providing high-quality services and/or limiting health spending in the years leading to the modifier’s effective date could receive higher pay that will vary based on the number of practices that receive modifier pay decreases.


From pg 8

Geographic payment adjustments: Medicare’s

disputed borders

equitable if it factored in unique costs to rural physicians, such as travel expenses and access issues. In 2010 testimony, Michael Kitchell, MD, past president of the Iowa Medical Society, questioned why rural doctors’ rates were so low compared with other states. “There simply is a point at which substantial inequities in Medicare payment make it too difficult for a low-paid state to effectively manage the costs of advancing technology in medical administration, as well as medical diagnosis and treatment, increasing demands of the regulatory system, and the growing needs of an aging citizenry,” Dr. Kitchell said. “For Iowa, that point has been reached.” Texas also has experienced growth spurts in such places as Sugar Land and Plano, which once were classified as rural but now should be considered urban, said Michael E. Speer, MD, president of the Texas Medical Assn. Many physicians in cities want rates to be readjusted to account for their higher rents and other overhead costs. But raising rates for some would mean lowering pay for others due to the budget-neutrality requirement. Physicians in Texas and Georgia say they don’t want rural doctors’ fees to drop because urban doctors get more. “We would like to see them raise rates across the board, given that they haven’t been raised above

inflation for a decade,” Dr. Speer said. “Instead of dealing with 10% here or 10% there, I would rather address the whole issue of inadequate payment.” The American Medical Association has long advocated that any changes to geographic pay rates not be subject to budget-neutrality requirements. Divining the costs of providing care Medicare uses a complex system when adjusting payments to reflect the costs of practicing medicine across the country. Such expenses as rent, staff salaries and the cost of living in an area are designed to be reflected in pay rates, said Steve Zuckerman, PhD, a senior fellow at the Urban Institute in Washington. Zuckerman was involved in researching a Medicare geographic adjustment system in 1989-90. Prices for goods and services, including medical care, vary in all 50 states. The Bureau of Labor Statistics keeps national and localized consumer price indices for a range of these goods and services. Since the baseline years of 1982-84, costs for medical care have increased by more than 430% in the Midwest urban centers of Chicago, Gary, Ind., and Kenosha, Wis. In New England, they’ve increased by 570%, according to the bureau.

Continued...

The California Medical Assn. has argued for Medicare geographic payments to be based on actual market costs. The association, which represents physicians in both rural and urban areas, said any payment changes should more precisely reflect the costs of running a practice from each type of locale. “The current system is outdated and not distributing payments accurately,” said CMA President James G. Hinsdale, MD. “A great example is San Diego, a county that is still designated as rural and clearly is not. Our belief at CMA is that payment accuracy will help to improve seniors’ access to care in these underpaid regions.” Providers in Iowa have argued that the current system would be more


From pg 09


disputed borders

In North Carolina, for instance, which has a statewide pay area, the 2013 GPCI for work is 0.971, practice expense is 0.927 and liability is 0.695. In Portland, Ore., the figures are 1.005 (work), 1.044 (practice expense) and 0.625 (liability). Taken together, those figures would lead to higher pay for services in Portland. However, there is a second force affecting geographic adjustments, Zuckerman said — Congress. Lawmakers in recent years have adopted Medicare payment legislation to change the geographic indexes and prevent them from decreasing rates by the full amount in areas deemed to be low-cost. Since 2004, the adjustment for work has been raised to 1 for all locales with index values below that floor. The provision, which costs about $500 million a year, expires Dec. 31. If Congress extends it, North Carolina’s work GPCI would be raised from 0.971 to 1 in 2013, almost the same as Portland’s 1.005 figure. Federal law mandates that the work adjustment in Alaska be set at 1.5. The 2010 health system reform law also set a practice expense floor of 1 for so-called frontier states, those with a majority of counties having six people or fewer per square mile — a list that includes the Dakotas, Montana, Nevada and Wyoming. Rate protections for hospitals and physicians in frontier states will cost Medicare $2 billion from 2010-19, according to the Congressional Budget Office. “The frontier states provision is about fairness,” said

Rep. Rick Berg (R, N.D.) in 2011 during debates on eliminating the pay floor to reduce federal deficits. “We believe that the frontier states provision is needed to protect seniors’ access to care in rural states like North Dakota and Montana.” Resistance to new payment borders Supporters of payment floors that counteract the Medicare geographic pay system cite their necessity for patient access in rural and other underserved areas. By receiving higher rates than Medicare has intended for areas deemed low-cost, enough physicians in those regions will be able to run profitable practices that meet seniors’ health needs, they said. But physician work force shortages persist even though Congress regularly has raised pay in rural areas, said the Urban Institute’s Zuckerman, who was part of a recent Institute of Medicine committee tasked with studying geographic pay reforms. Some urban areas with higher rates also have work force problems. Bruce Steinwald, an independent consultant who also served on the IOM panel, suggested that work force initiatives be more targeted and not rely on geographic adjustments. For instance, physicians could receive subsidies or participate in loan-forgiveness programs for practicing in designated shortage areas.

Continued...

CMS is required to account for such price differences using indexes that adjust the portions of doctors’ fees attributed to practice expenses, medical liability costs and the amount of physician work required to provide care. Each locale has geographic practice cost indexes, or GPCIs, that are multiplied by the relative values corresponding to each of these factors, which then impacts the final amount that Medicare pays a doctor for a given service in a particular area. The current GPCI locality map was charted in 1997. There are 89 total localities: 36 statewide areas, such as Colorado and Montana; 37 higher-cost locales for urban centers, such as Miami and St. Louis; and 16 “rest of area” jurisdictions for settings outside of cities in states such as Texas and Virginia.


From pg 10


disputed borders

“The byproduct of more payment localities is some shift from rural to urban,” Steinwald said. “Taken as a whole, it’s hard to generalize, and it’s not true in every case.” Medicare already uses 441 jurisdictions to adjust payments to hospitals. The implementation of shared savings programs and accountable care organizations — in which hospitals and physicians work together to improve quality of care and restrain costs — should strengthen the case to align geographic adjustments between the physician and hospital sides of the program. “It makes sense to use the same payment areas,” Zuckerman said. The Medicare Payment Advisory Commission also recently studied geographic adjustments and recommended that Congress stop raising the GPCI work floor year after year. The action by lawmakers to preserve the higher rates for rural areas is a scattershot approach to solving patient access issues, MedPAC members said. One analysis shows that even communities without access problems benefit from the floor. The IOM and MedPAC recommendations, however, received a cool reception from CMS and rural lawmakers in Congress, both of whom have given little indication that they would entertain such an overhaul anytime soon. Although the approach is not perfect, raising the floor

does help rural areas, said MedPAC Commissioner Alice Coombs, MD, a critical care specialist and anesthesiologist at Milton and South Shore hospitals in Weymouth, Mass. A better plan in her estimation would be to continue the work floor while a new strategy is developed. “Now, that’s in a perfect world,” Dr. Coombs said. “I know you can’t have everything the way you want it.”

Location, location, location matters for Medicare pay, too Physicians in California repeatedly have called for revising geographic Medicare rate adjustments to reflect more accurately the costs of running practices in different parts of the state. Santa Cruz has a population of 270,000, but it is defined under the system as a lower-cost, rural jurisdiction, along with 46 other counties in the “rest of California.” Some doctors say the resulting lower payments have led to a low number of physicians in Santa Cruz. This comparison is based on 2012 pay rates and includes cities within roughly 50 miles of each other.

The IOM committee recommended a coordinated approach to work force problems along with a major overhaul of the geographic system. In 2011, an IOM report advocated for drawing a new map to adjust physician payments with 441 markets instead of the current 89. This level of specificity, along with other IOM recommendations, would increase the accuracy of payments throughout the country, the authors said. Such changes would lead to an average pay reduction of 3% to physicians in nonmetropolitan areas and an average increase of less than 0.5% for doctors in metropolitan counties, though some individual counties could experience double-digit rate changes, according to another IOM report released July 17 of this year.


From pg 11


disputed borders

AC – acromioclavicular ACL – anterior cruciate ligament Add. or add. – adduction ADL’s or ADL – activities of daily living ad lib – at discretion adm – admission/admitted AE – above elbow AIIS – anterior inferior iliac spine AJ – ankle jerk AK – above knee ALS – amyotrophic lateral sclerosis a.m. – morning AMA – against medical advice amb – ambulate, ambulates, ambulated, ambulatory, ambulation

Ant. – anterior AP – anterior-posterior approx. – approximately (also “~” symbol can be used) AROM – active range of motion

AROME - active range of motion exercise/s ASAP or asap – as soon as possible

ASIS – anterior superior iliac spine Assist. – assistive, assistance

B

B/S – bedside BE – below elbow bed mob. – bed mobility BID or bid – twice a day bilat – bilateral (a B enclosed within a circle may also be used) BK – below knee BKA – below knee amputee, below knee amputation BOS – base of support BP – blood pressure bpm – beats per minute Continued...

A

@ – at ā – before A: – assessment AAROM – active assistive range of motion Abd. or abd. – abduction ac – before meals


Special Abbreviation Reference Section

CAT – computerized axial tomography C/C – chief complaint

cc. – cubic centimeter cerv. - cervical CHF – congestive heart failure CHI – closed head injury CKD – chronic kidney disease cm. – centimeter CNS – central nervous system Cont. or cont. – continue

COTA – certified occupational therapist assistant CP – cerebral palsy CRF – chronic renal failure CSF – cerebrospinal fluid CWI – crutch walking instructions CXR – chest x-ray Cysto – cystoscopic examination

D

D/C – discontinue, discontinued, discharge, discharged dept. – department DF - dorsiflexion DIP – distal interphalangeal DJD – degenerative joint disease DM – diabetes mellitus DOB – date of birth DOE – dyspnea on exertion DTR – deep tendon reflex DVT – deep vein thrombosis Dx – diagnosis

E

ECF – extended care facility ECG/EKG – electrocardiogram, electrocardiograph Continued...

BR – bedrest BLE – both lower extremities BUE – both upper extremities

C

_ c - with c/o – complains of


From Page 3

ext. – extension

F

FBS – fasting blood sugar FEV – forced expiratory volume FH – family history flex. – flexion FRC – functional residual capacity FVC – forced vital capacity FWB – full weight bearing Fx., fx – fracture

G

GB – gall bladder GI – gastrointestinal GIT – gastrointestinal tract

H

H/A - headache HEENT – head, ear, eyes, nose, throat Hemi. – hemiplegia, hemiparesis HEP – home exercise program HKAFO – hip knee ankle foot orthosis HNP – herniated nucleus pulposus h/o – history of HOB – head of bed HR – heart rate hr. - hour hs – at bedtime HTN or Htn – hypertension Hx – history Continued...

ED – emergency department EEG – electroencephalogram, electroencephalograph EENT – ear, eyes, nose, throat

EMG – electromyogram, electromyography, electromyography ER or Ext. rot. – external rotation E.R. – emergency room eval. – evaluation

Ex. - exercise


From Page 4

IM – intramuscular imp. – impression indep – independent inf. – inferior inv. - inversion IR or int. rot. – internal rotation IV – intravenous

K

KAFO – knee ankle foot orthosis kcal – kilocalories KJ – knee jerk KUB – kidney, ureter, bladder

L

L within a circle – left Lat – lateral

LBBB – left bundle branch block LBP – low back pain LE – lower extremity LOC – loss of consciousness, level of consciousness LMN – lower motor neuron LMNL – lower motor neuron lesion LOS – length of stay LP – lumbar puncture LLQ – left lower quadrant LQ – lower quadrant LTG – long term goal LUQ – left upper quadrant

M

MAP – mean arterial pressure max. – maximal Meds. – medications Continued...

I

I&O – intake and output IADL – instrumental activities of daily living ICU – intensive care unit IDDM – insulin dependent diabetes mellitus IE – initial evaluation IFC – interferential current


From Page 5

MVA – motor vehicle accident

N

NDT – neurodevelopmental treatment neg. – negative NG or ng – nasogastric N.H. – nursing home NIDDM - non-insulin dependent diabetes mellitus nn. – nerve noc – night, at night NPO or npo – nothing by mouth NSR – normal sinus rhythm NWB – non-weight bearing

O

O: - objective OA – osteoarthritis OBS – organic brain syndrome

od – once daily OOB – out of bed O.P. – outpatient O.R. – operating room ORIF – open reduction, internal fixation OT – occupational therapist/therapy OTR – registered occupational therapist

P _

p – after P – poor (used in muscle testing) P: - plan P.A. – physician’s assistant PA – posterior/anterior para – paraplegia Continued...

min – minimal min. – minute mm. - muscle MMT – manual muscle test, manual muscle testing mod. – moderate MP – metacarpophalangeal MS – multiple sclerosis


From Page 6

PNF – proprioceptive neuromuscular facilitation PNI – peripheral nerve injury POMR – problem-oriented medical record pos. - positive poss – possible post. – posterior post-op – after surgery PRE – progressive resistive exercise

pre-op – before operation Prep. – preparation prn – whenever necessary PROM – passive range of motion PROME – passive range of motion exercise

PSIS – posterior superior iliac spine PT – physical therapy/ therapist Pt. or pt. – patient PTA – prior to admission PTA – physical therapist assistant PTB – patellar tendon bearing

PVD – peripheral vascular disease PWB – partial weight bearing

Q q – every

qd – everyday qh – ever hour qid – four times a day qn – every night

R

® - right RA – rheumatoid arthritis R.D. – registered dietitian Rehab – rehabilitation reps. – repetitions Continued...

pc – after meals PCL – posterior cruciate ligament per – by/through PF – plantar flexion p.o. – by mouth (per orem) P.H. – past history p.m. – afternoon PMH – past medical history


From Page 7

R.T. – respiratory therapist/therapy Rx – prescription; therapy; intervention plan; treatment

S

_ s – without SACH – solid ankle cushion heel SBA – standby assist SCI – spinal cord injury SC jt. – sternoclavicular joint sig – directions for use; use as follows; let it be labeled SI jt. – sacroiliac joint SLP – speech-language pathologist SLR – straight leg raise SNF – skilled nursing facility SOAP – subjective, objective, assessment, plan SOB – shortness of breath

S/P – status post S/Sx – signs and symptoms stat. – immediately or at once STG – short term goal sup. – superior Sx – symptoms

T

tab – tablet TBI – traumatic brain injury TENS or TNS – transcutaneous electrical nerve stimulator/ stimulation THA – total hip arthroplasty THR – total hip replacement TIA – transient ischemic attack tid – three times daily Continued...

resp – respiratory, respiration RN – registered nurse R/O or r/o – rule out ROM – range of motion

ROME – range of motion exercises rot. – rotation RR – respiratory rate RROM – resistive range of motion


From Page 8

TV – tidal volume Tx – treatment tx – traction

U

UA – urine analysis UE – upper extremity US - ultrasound UV ultraviolet

V

VC – vital capacity VC – verbal cues VO or v.o. – verbal orders Vol. – volume v.s. – vital signs

W

w/c – wheel chair WFL – within functional limits wk. – week WNL – within normal limits wt. – weight

X x – number of times performed (e.g. x3, x8, etc.)

Y

y/o or y.o. – years old yr. – year

TIW – three times per week TKA – total knee arthroplasty TKR – total knee replacement

TMJ – temporomandibular joint TNR – tonic neck reflex t.o. – telephone order TPR – temperature, pulse and respiration TTWB – toe touch weight bearing


From Page 9

Citations

Fiegl, Charles. "Decisions Doctors Must Make to Avoid Medicare Penalties." - Amednews.com. American

Medical Association, 12 Nov. 2012. Web. 30 Nov. 2012. <http://www.ama-assn.org/amednews/2012/11/12/

gvsa1112.htm>.

"Importance of Preparing/Maintaining Legible Medical Records." Centers for Medicare and Medicaid

Services. U.S. Government, 26 Nov. 2012. Web. 27 Nov. 2012. <http://www.palmettogba.com/

palmetto/providers.nsf/ls/J1B~92ELEB5100?

opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email>.

Mangusan, David, Jr. "PT Abbreviations | Physical Therapy (PT) Notes." PT Abbreviations | Physical

Therapy (PT) Notes. Physical Therapy.com, n.d. Web. 28 Nov. 2012. <http://

www.physicaltherapynotes.com/p/pt-abbreviations.html>.

Steele, Evan. "Audit Risk: EHR Coding, Cloning, and Templated Notes." EMR Straight Talk Audit Risk EHR

Coding Cloning and Templated Notes Comments. SRSsoft, 17 Oct. 2012. Web. 30 Nov. 2012.

<http://blog.srssoft.com/2012/10/audit-risk-ehr-coding-cloning-and-templated-notes/>.


The 4-1-1 On Us! Clinical Practice Management’s (CPM) story began in 1998 by a group of Physical Therapists who decided to provide, what they themselves were looking for, in a billing company. • Compliance • Compassion • Knowledge • Integrity • ...and of course...Cash!

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