Supervision of Support Personnel in the Use of Modalities - Essay Example

Eg Supervision of Support Personnel in the Use of Modalities One of the first interesting pieces of information to arise regarding my prior readingdone in the area of electrotherapeutics was the uncertainty in the professional literature regarding their effectiveness. This was particularly borne out in the paper by Robertson and Baker (2001:1339) where they state that while "therapeutic ultrasound is one of the most widely and frequently used electrophysical agents the effectiveness of ultrasound for treating people with pain, musculoskeletal injuries, and soft tissue lesions remains questionable." Their metaresearch paper as reported in Physical Therapy (81:7) is, in fact, quite unequivocal: "There was little evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing." However, they went one step further and added that in the few studies which remained and with whose internal validity they were satisfied with, "The dosages used in these studies varied considerably, often for no discernable reason" (ibid.). While my interview and the knowledge I got out of it were based on the clinic's practice of using ultrasound as one electrotherapeutic modality, I did keep in the back of my mind the findings in the above-cited study and wondered what specifically it would mean for my daily practice in the future. From my interview, a lot of clarifications arose regarding frequency of use of the identified modality and the daily logistical, legal and ethical considerations in the practice of the clinic. The interview highlighted the surprising fact that ultrasound was a modality whose use was only minimal at the clinic and then only to break up fibrotic tissue in an attempt to reduce swelling and chronic pain. The dosage used for chronic swelling was pulse ultrasound at 20% duty cycle while for chronic pain continuous ultrasound at 1.5 MHz for 5 minutes was administered. With regard to the expected therapeutic outcomes and the criteria affecting discontinuation of treatment, the interview identified reduction in both pain and swelling as obvious therapeutic outcomes as measured by a pain scale and reduction of diameter (girth) of swelling. Treatment was discontinued after 8-10 visits because research showed that by the end of that time period, the maximum benefit from electrical stimulation would have been reached. The reason ultrasound (CPT code 97035) was used for pain control and soft-tissue shortening was because of the therapeutic benefits of localized heat (between 1-4C tissue temperature elevation) as regards increased metabolism, decreased muscle spasms and increased blood flow to the localized site (and thus enhanced healing opportunities). I was also aware that there were non-thermal effects such as stable cavitation, auto streaming and microstreaming and the use of US in special situations where very low doses (0.15W/cm sq intensity at 20%duty cycle) were beneficial to the healing of bone fractures. However, my interview focused on the use of US for mainly soft tissue repair at the clinic, the parameters used, billing and reimbursement procedures, legal and supervisory requirements for setting up a session and the legal limitations placed on differing categories of health professionals. For example, in my interview with the physiotherapist in the clinic, it became clear that supervisory guidelines prohibited technicians from turning on the ultrasound machine although they could set up the patient by applying ice or heat as appropriate (CPT 97010). This was covered in state law under section 500 of the "Covered services, limitations, and exclusions for occupational/physical therapy services" (Department of Health and Human Resources, rev. 2005) which specified that medical services were to be carried out in line with Title XIX of the Social Security Act and Chapter 9 of the West Virginia Code. In fact section 550 (2005:4) of the West Virginia Department of Health and Human Resources specifically stated that the WV Medicaid Program would not pay for occupational / physical therapy services provided by persons who were not licensed or certified and enrolled in the WV Medicaid Program (technicians). PTAs employed by the clinic on the other hand, in accordance with WVMI legislation, were able to carry out all aspects of an electrotherapeutic treatment and were even able to have their own patient load although they remained under the continuous guidance of the PT through a system of all notes being counter-signed by the main PT prior to commencement of a course of treatment. In this way a qualified PT was able to verify that the correct parameters were being used. As well, even though the use of a particular modality (here ultrasound) was decided by the clinic director and the therapist in line with patient needs at an in-service meeting, any complaints or adverse reactions were reported to the PT if it was reported by a technician or patient but was required to be a short written report if it was reported by a PTA in the first instance. However, as the Department makes clear in Section 540 of the "Covered services, limitations, and exclusions for occupational/physical therapy services" (2005:3), in all cases, PTs were to obtain prior authorization using the Occupational/ Physical Therapy Services Prior Authorization Request Form and submit this request to the West Virginia Medical Institute before any services were rendered. The billing practices of the clinic were strictly aligned with the WVMI guidelines. Thus, it was the responsibility of the service provider to verify Medicaid eligibility for each potential client before that client received services. This was because gaps in Medicaid eligibility could occur, with an individual ineligible for Medicaid coverage at the time of a specific treatment (Department of Health and Human Resources, 2005:2). Therefore, it was recommended that the therapist review the individual's medical care before provision of each service because even if the PT sent in a Prior Authorization Request Form, prior authorization did NOT guarantee payment if the client was ineligible for Medicaid benefits. All PT charges at Inoxa were entered into the database, with the main building at Fairfax responsible for all data input and records before it was submitted to Medicaid for payment. At the clinic, clients' insurance companies were generally billed electronically where the insurance company had set up this facility. This was done using the professional claim format, ASC X12N 837 (004010X098A1) for electronic or CMS -1500 paper claims. I also learned that if, on the other hand, occupational and physical therapy services were provided in an outpatient hospital setting, then PTs used the Institutional format, ASCX12N 837 (004010X096A1) or the UB92 paper claim. Charges by PTs are standard across all modalities. If it was billed as 'manual therapy of therex' it cost $45 per fifteen minute session in line with CPT Code 97035 "Application of a modality to one or more areas; ultrasound, each 15 minutes" (Department of Health and Human Resources, 2005:9) It was clear from my interviews and observations what the requirements of WVMI were as regards allocation of duties and procedures for support personnel using US at this clinic. This was both a safety issue (client safety) and insurance issue (threat of litigation). I also learned the details of the Code listings for the various billing procedures and what the format for that procedure was. I think that, in the main, my observations and visit were consistent with my expectations in all the practical aspects (benefits, dosage, dangers, line management structures and billing practices). I was rather surprised to read the findings of the Robertson and Baker (2001) study (see works cited) and this has created a nagging question in the back of my mind now: will I be doing the right thing Will it be effective Are there a hundred other studies counterclaiming the findings of Robertson and Baker Do I need to skill myself in other areas to remain relevant and employable I suppose time will tell. Works Cited Department of Health and Human Resources. "Covered services, limitations, and exclusions for occupational/physical therapy services". Chapter 500: (revised May2005): 1-11. Majlesi & Unalan. "High-Power Threshold US Techniques in the Treatment of Active Myofascial Trigger Points: A Randomized, Double-Blind, Case-Control Study." Archive of Physical and Medical Rehabilitation. 85. (2004): 833 - 836. Merrick et al. "Identical 3 MHz Ultrasound Treatments with Different Devices Produce Different Intramuscular Temperatures." Journal of Orthopaedic Sports and Physical Therapy. 33. (2003): 379-385. Physical Therapy and Rehabilitation Services (2003) PLEASE CHECK THE EXACT REFERENCE DETAILS OF THIS DOCUMENT, AS IT WAS NOT AVAILABLE IN THE EMAIL YOU SENT ME Robertson, V.J. and Baker, K.G. "A Review of Therapeutic Ultrasound:Effectiveness Studies." Physical Therapy. 81: 7 (2001): 1339-1350. Read More