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REP 18 - Which is which: choosing how to record physiotherapy and exercise sessions


Susan Paul, PT

Many physiotherapists come into the profession with other skillsets, or pick up other certifications along the way.  It is important to remember that while some of the skills we use may be valuable tools in our physiotherapy toolbox, on their own they cannot be called “physiotherapy” or billed as such.

The following article was recently published in the College of Physical Therapists of British Columbia newsletter on “Clinical Pilates” and has some helpful information on determining when pilates can be considered part of a physiotherapy session and when it should be seen as a pilates exercise session.

Republished with permission, CPTBC:

 

"The College continues to receive questions about 'clinical pilates' and whether or not it can be billed as physical therapy. The answer is that only physical therapy can be billed as physical therapy services.  

Most Colleges have Bylaws or Practice Standards that set out minimal treatment standards as well as documentation requirements.  

In some cases, physical therapists integrate Pilates exercises into the individualized physical therapy treatment plan to accomplish specific physical therapy goals, and Pilates exercises are another 'tool in the toolbox' of the physical therapist. 

However, in other cases, the service provided is not physical therapy but rather a Pilates session.

The physical therapist therefore must determine whether:

1. Pilates techniques were used as part of the individualized physical therapy treatment plan, to accomplish physical therapy goals that flow from the findings in the physical therapy assessment. If so, the clinical record reflects a physical therapy assessment and treatment plan, with reassessments and treatment progression. 

Be sure to chart all of the treatment provided - education, postural correction, specific Pilates techniques, any hands-on cueing, as well as any other treatment techniques or modalities. 

OR

2. The service provided to a patient is a Pilates session, and not a physical therapy session, in which case a physical therapy receipt must not be issued. 

In cases of audits by third parties, clinical records may be reviewed and if receipts were submitted for physical therapy services but the clinical record does not support that physical therapy services were provided, the patient may be asked to reimburse the insurer for the amount submitted as physical therapy services.   

The public should always be clear about what service they are receiving, and the clinical record as well as the receipt provided should be consistent with that service. Although in this case it is applied to Pilates, it has relevance to other ‘tools’ that we may use (for example, Yoga or Tai Chi) and therefore worthy of our reflection. "

 

Over to you

What other practices in your treatment plans would you like more clarification on?

 

By Susan Paul, PT
 

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Comments

Thanks for another great posting to increase transparency of practice.  

As a practitioner for over 25 years with additional continuous learning in acupunture, mindfulness based stress reduction training, pain care yoga learning, courses in psychologoical approaches to address pyschosocial risk factors to rehabilitaiton recovery -- I've sought out these complementary practices to augment/enhance the effectiveness of  my physiotherapy practice for specific individuals with specific issues.

I have always felt that these methods always need to be linked back to my assessment, client goals and measuring client ouctomes.  

From a documentation point of view my intent has always been to the following visible for another professional reviewing my charting:

1.why I was using these approaches  2.how did I used them in sessions or education  3. what was client response/feedback,  4. document any adjustments made to techniques with rationale and linked back to goal (initial or progressive depending on client response to treatment).  Just like I would do for any physiotherapy modality, manual technique, exercise approach or education session.

I've always think about my end point -- in terms how do I use any of my physio/complementary approaches to foster self-management vs fostering dependence on me as the "expert".    

As part of a chronic disease/health promotion model to my practice this means I make myself available as a consultant or resource to the client in future -- but if booking appointments my patients know they need to come with  a specific issue/goal  that we explore togther.   I use this later approach as a method to monitor case periodically as part of ongong primary care for chronic disease and multiple comorbidities.  

Appreciate the platform 30 reps has created to share experience and questions.

Feedback, thoughts, questions are welcomed.

:)

 

 

Thank you for your comments.  We appreciate your contribution to this important conversation.

@CPA_Melissa

Still not clear.... By this interpretation of distinction between "physiotherapy service" and an "exercise service" does this mean that a physiotherapist can't run a program such as GLA:D (specific OA research evidence based standardized protocol franchised program) or "Delay the Disease" (a Parkinson's research evidence based standardized franchised exercise program as well) and charge in under physiotherapy? Yes, there are standard intake assessment baselines and re-assessment exit re-test at the end of a set period ie: 8 weeks but it is not identified as the only or best recommendation for that person based on an unbiased assessment (as all the applicants have come for these specific programs only in a group format) and are assessed for the purpose of this specific group treatment as it may be the only way an individual gets disease specific "physiotherapy" treatment they can afford? But in the strict "litmus" test the above has been delineated, it would fail as it is the ONLY treatment methodology being presented and assessed from only that perspective. It is by all definitions "a conflict of interest" and not "unbiased"; as we would know there would be potentially other treatment methods that might be more appropriate, the advertising targetted only for this one type of "treatment".

Am I correct in this assumption of interpretation from the blog or would you interpret it as appropriate physiotherapy? I am intersted in the why in either outcome answer scenarios? Obviously, I would define it as "physiotherapy" from my set-up of comments and would disagree with a finding of "exercise" only not billable as physiotherapy. It's being done out there like this, though I don't run classes as such but I would have, if I had the time resources. There are clinics out there paying a lot of franchise fees for these type of research evidence based exercise programs and it would probably be a loss to not be able to charge it as physiotherapy, I would imagine, especially in low density rural/urban settings.

 

 

Exercise Classes

Thank you for your comments, and we hope that this helps to clarify.

As physiotherapists, we have a multitude of tools in our tool box.  Exercise is, no doubt, the biggest among them. When used as part of the therapeutic process, including assessment, goal setting, reassessment and collection of outcomes, then exercise classes can certainly be considered ‘physiotherapy’ without the use of other modalities or manual therapy techniques.  In some cases, physiotherapy including exercise in group settings, has proven to be more effective than one-on-one treatment. We view evidence based exercise classes such as GLA:D as following the therapeutic process and would be considered physiotherapy. 

When exercise classes are used, and there is no evidence of assessment, goal setting, reassessment, and the collection of outcomes- then we would argue that this is an exercise class, and should not be billed as ‘physiotherapy.’

As always, know your regulations and standards of care for the jurisdiction in which you practice, and ensure that you are transparent in your billing practices.

@CPA_Melissa

@CPA_Chantal

 

I also feel like this post raises more questions than it answers. The use of Pilates is particularly relevant to my own practice. I use Pilates-based exercises to address the findings of my assessments and help patients reach their functional goals. I chart on what I do, re-assess at every session as I do for all my outpatient, private-practice clients, and discharge patients when goals have been reached. However, from the post above, I'm led to believe that because the exercises I teach and prescribe can also be described as Pilates, that I am operating in an insurance "gray zone." I'm hoping you can provide a concrete example of when a session "is a Pilates session, and not a physical therapy session." 

I understand that this post may raise a lot of questions.  

From you post, it sounds like you are using pilates as a tool in your physiotherapy toolbox.

In my mind, there is a differnce between a pilates session and a session of physiotherapy that is inclusive of pilates.  In the second instance, there is clear evidence of application of the therapueitc process (assessment, goal setting, reassment, treatment progression, and collection of outcomes). When in doubt, contact your provincial/territorial regulatory body for clarification.

Thanks for taking the time to join the conversation.

@CPA_Melissa

Isn't the question here one of when you incorporate Pilates, or other alternative movement therapy, into your physio treatment, that is billed as physiotherapy, however, when you send your client off to a clinic-provided Pilates session, led by a kin, or certified Pilates instructor, not a PT, that you cannot bill that as a physio visit?  

This article and others like it seem to miss the consequence of applying such a limited and inflexible interpretation of the profession and its scope.  The PT profession is facing increased pressure to compete with many other stakeholders, including those trained in various forms of movement and exercise.  If the profession cannot configure an identity that permits an inclusive billing system, then it will ultimately lose that shrinking piece of the health care pie.  There are many others out there who are quite capable of offering pilates or yoga, etc., etc., and who do not need to worry about bumping into trouble with the college because they are not PTs. 

I fail to see the wisdom in such a direction, but it may be inevitable that the profession will end up sacrificing itself in failing to address these issues. 

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