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Toni Talks about PT Today

Don’t Tell Me to Ignore the Practice Act

Published January 22, 2009 8:29 AM by Toni Patt
I heard something today I just couldn't believe. I was talking to the department manager about who is responsible for putting patients back to bed. My point was in order for physical therapy to be physical therapy, a skilled intervention must be involved. The intervention must be goal driven toward a functional outcome. I've said this before.  What took my breath away was his response. I was told he didn't care about the practice act or what is functional. Nursing is short staffed. If nursing asks me to put a patient back to bed I am to do it and do it with a smile on my face. He went on to acknowledge that was a job duty of a CNA. He told me charges don't matter because our reimbursement is DRG driven. He only cares that the patient be happy and willing to return to the facility. If good patient care means I put the patient back to bed, I should put the patient back to bed.

I have no problem with providing good patient care. I go out of my way to take care of my patients. My problem is being told I should disregard the document which governs how I practice. My problem is being told to perform non-skilled interventions because nursing is telling me to do so. I have a problem when the department carries patients on caseload for the sole purpose of lifting them out of bed and charging that as a skilled service. That is called fraud. Not only does Medicare frown on that, it is illegal.

I don't know what to think. Physical therapy has spent years educating other health care professionals on what we do. PTs are recognized for their skills in treating neuromuscular disorders.  That is one of the principles behind the push for the DPT. For a fellow PT to tell me to ignore the practice act is beyond me. If I practice outside the practice act, I lose my license. If I provide unskilled services and charged them as skilled services, I am committing fraud and can not only lose my license, but go to jail.

It would be one thing if he told me to suck it up because that is department policy. I wouldn't be happy, but it wouldn't be heresy. This man has gone so far to the dark side even he makes Darth Vader seem good. At least Darth had principles. It doesn't matter to me that this situation isn't a frequent occurrence. It's going to happen. When it does, I deal with it.  What matters is that this manager equated what I do with what a CNA does. Instead of defining our profession, he let us down.

I don't know what to do. Up until today, I enjoyed working at that facility. I'm not fond of the man, but respected his position.  Now I'm not sure he deserves his position. I can report him to the Texas board, but I don't think anything will result. Since no one else heard him, it's my word against his and I doubt they'll act on that. I can ask to be transferred, which gets me away from the problem. I can go to his superior, but I suspect an administrator would be more concerned about the patient coming back then this. No matter what, I'm not going to do what he said. I can only be responsible for myself. When I find myself in this situation, I'll find an acceptable way to deal with it that makes the patient happy and is within the practice act.  


This is my first time ever to enter a view on a blog. Have just recently begun viewing them, and wish they could be a resource for policy makers and administrators. Nevertheless, I walked away from Toni's post about "putting patients in bed..." (paraphrasing), and felt compelled to respond. After blundering my way through other blogs, I got back. So, I will agree that all too often a blanket "mobility" or "ROM" or "out-of-bed" directive will be written in physician's notes section of a chart, leading to sometimes inappropriate use of skilled therapies to do rote tasks which should be performed by trained support staff. That being said, it is our skilled eyes, hands, and ears that make the experience of getting in and out of bed a therapeutic experience and at least an educational experience. So -- I would look at where the "order" is coming from: If it is indeed coming from nursing or administrative staff asking for "team-playing" in the overall care of a patient, I agree with Toni whole-heartedly. Using skilled personnel for these purposes is just dumb -- poor management, except for rare occasions. Furthermore if that same administrative person is wanting to bill for these moments of filling in for short-staffed nursing as skilled care, by all means a report to the appropriate agency would be indicated.  However, If the order is coming from the physician's plan, requests, etc etc -- even if worded as a "screen" "out-of-bed" then our skilled services apply and should be billed. We all know that 90% of the time, our screens may as well be evaluations because we can gather as much information in the time purusing the chart and our brief meeting with the patient as we could in an official evaluation.  We also know that we can train and re-train nursing staff until the end of time on the proper techniques for safely, smoothly, and efficiently getting patients in/out of bed to little effect; and will have even lesser chance of ever conveying the concept of facilitating the patient when getting in and out of bed.  So, if a generalized "almost order" came from the physician -- take it and build a plan of some kind: restorative care or skilled care -- but build the plan, and bill for the eval. If just short staffed, a policy should be in place that says skilled care does not step in unless the need is emergent. The fact the man said "billing doesn't matter because everything is DRG driven" is disgusting! A prime example of how Medicare in it's infinite wisdom dictates practices which cloud the lines of various interventions and lumps people into diagnostic categories with outrageous expections for all providers to meet all needs within an inhumane budget. Which leads me to:

Please view, sign, comment, and pass on. It is just a summary but we need to speak up before Medicare becomes the one and only. Thanks.

Mary , PT February 7, 2009 7:06 PM

I don't think he's violating the practice act unless he's telling you to "bill" for it or account for it in your time somehow.  

I wouldn't have a problem with this as long as it was recognized that this is not skilled intervention and that it does not affect any productivity standards that are placed upon me.  

If he told you to do this, account for this in your billing (even if it is DRG driven) and if you are still held to a productivity standard, then I would have major problems with this.

If the hospial wants to pay me as a PT, but have me act like a CNA, so be's a waste of their own money...just dont' expect me to do anything illegal or then place a productivity standard on top of it.

Christie , Physical Therapist January 27, 2009 9:10 AM
Streamwood IL


Good patient care is what we should always do.  To ignore the practice act is wrong - follow professional judgement and you will not go wrong.  

However, if a patient is thirsty do you offer a drink to them, or is that not a skilled treatment so you defer to nursing?  How about if the patient is cold.  Do you tell the patient to push the call button and ask nursing for a blanket.  

Common sense should dictate our care, but the rules that govern our profession limit what we do as far as "skilled" services.  

Karen January 22, 2009 10:04 AM

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