The Centers for Medicare and Medicaid Services (CMS) states that to be covered, skilled therapy services must meet the following conditions:
• Ordered by a physician
• Be related to an active written treatment plan
• Be of a level of complexity and sophistication requiring the judgment, knowledge, and skills of a therapist
• Accepted under standards of medical practice
• Are reasonable and necessary
The majority of therapy billing claim denials result from failure to establish the need for skilled therapy or to adjust the plan of care in response to patient progress (or lack thereof). Adjustments to the plan of care should occur regularly to keep the patient on track toward their therapy goals.
Therapy documentation should reflect what skilled services the clinician is providing, not simply a description of what the patient is doing. Examples include:
• Providing verbal and/or tactile cues to facilitate movement quality (e.g., upright posture/core stability during activity)
• Adjustments to the patient or cycle to prevent abnormal limb movement such as excessive scapular protraction or hip ab/adduction
• Monitoring patient response to treatment (e.g., blood pressure, heart rate, oxygen saturation, dyspnea scale response, RPE scale response, observation for facial expression/ color/diaphoresis) and adjusting the exercise “dose” to maintain target heart rate
Examples of Skilled Therapy Adjustments Related to use of the OmniCycle®:
• Adjust the exercise session duration in response to improvements in patients’ endurance
– Start at 5-10 minutes and over time, increase the duration as patient improves. Note: The
American College of Sports Medicine Position Stand on Exercise for Older Adults advises 20-30 minutes to achieve maximal benefits of aerobic exercise.1
• Adjust the resistance or work level to maintain target heart rate levels
• Adjust the RPM – Avoid having patients always exercise at a self-selected speed that does not change
– Cue the patient to increase their pace or coach them using interval training (1 min at high speed followed by 1 min of coasting) to meet their patient-specific exercise intensity targets.
– Set the RPM with the patient’s particular medical indications in mind – In a study of individuals with Parkinson’s disease, it was demonstrated that increasing speed to 30% greater than preferred voluntary rate resulted in improved motor function and bimanual dexterity.2
– Consider the Soccer biofeedback which adjusts RPM targets with active exercise: Minimal difficulty = 20-35 RPM, Moderate = 30-45 RPM, and Maximal = 40-70 RPM.
• Progress mode of cycling activity from assisted to active to active-resisted, as indicated
– Document the percentage of time the patient was “active” during the cycling exercise.
– Consider the Porcupine or Traffic Jam activities for symmetry motor control.
References:
1. www.acsm.org
2. Ridgel A, Vitek J, Alberts J. Forced, Not Voluntary, Exercise Improves Motor Function in Parkinson’s Disease Patients. Neurorehabilitation and Neural Repair 2009; 23(6): 600-608.
