Lafayette, LA 70507
Phone: 337.262.1043
Fax: 337.262.1054
Intra-State Toll Free: 888.400.9110
lsbpte@laptboard.org
Declaratory Statements - Practice Issues
04.11.03 Termination of Employment - A Physical Therapist Assistant was hired to work for a contract company that works for a nursing home and was told that he would work between two nursing homes that are 5 minutes apart to make his 40 hours a week. However, he was told after he was hired, that he could not go to the PTA did quit without notice?
A P.T. or P.T.A. needs to resign in accordance with Company Policy with a letter of resignation, outlining reasons for resignation. If the P.T. or P.T.A. terminated his/her without the required company notice of resignation, the employee would be at risk of being charged with patient abandonment. Patient abandonment would jeopardize the licensure in good standing of the employee.
02.07.01 Goals met for discharge - Petition: What is the course of action for a physical therapist working on a rehab unit when the therapist feels that the patient has reached the highest level of functional mobility possible and the rehab doctor insists on keeping the patient? Or if the PT feels that therapy can be continued on an outpatient or home health basis rather than an inpatient stay? Doctorýs reasoning for keeping a patient under these circumstances includes political ties within the hospital and ýnot angering another doctorý due to need for referrals. One patient was kept approximately 6 weeks functioning at a supervision level and ambulating approximately 400-500ý with supervision. The therapist, both PT and OT stated strongly at all interdisciplinary team meetings their feelings (also documenting). What happens if this medical record is called into question by Medicare? Are the therapist held responsible for continued care which they felt was unnecessary? Can the therapists legally discharge the patient from their services and place that patient on a maintenance therapy program? The concern is that of Medicare fraud and abuse and the legal action that could possible be enforced upon us?ý
To answer the question, one must review several documents, including the Louisiana Physical Therapy Practice Act and Rules and Regulations, the Code of Ethics of the American Physical Therapy Association, as well as possibly Medicare billing guidelines. The Rules and Regulations (Section 327, E, 5 on page 26) describes ýunprofessional conductý as the ýinitiation or continuation of physical therapy services that are contraindicated or cannot reasonable result in a beneficial outcome.ý Further, Section 2413 of the Louisiana Physical Therapy Practice Act outlines refusal, suspension, or revocation of license. Specifically, Section 2413A, 7 states
ýHas been found guilty of unprofessional conduct. Unprofessional conduct shall include departure from, or failure to conform to, the minimal standards of acceptable and prevailing physical therapy practice, in which proceeding actual injury to a patient need not be established.ý
Additionally, the Louisiana Physical Therapy Practice Act and Rules and Regulations hold each licensee for the Code of Ethics of the American Physical Therapy Association (Subpart 2, Section 305. Special Definition; Practice of Physical Therapy, B. "Minimal Standards of acceptable and prevailing physical therapy practice shall include but not be limited to the American Physical Therapy Association Code of Ethics").
The Code of Ethics of the APTA, section 4.1 Professional Responsibility is outlined as follows for your convenience: PRINCIPLE 4 A physical therapist shall exercise sound professional judgment. 4.1 Professional Responsibility A. A physical therapist shall make professional judgments that are in the patient/clientýs best interests.
B. Regardless of practice setting, a physical therapist has primary responsibility for the physical therapy care of a patient and shall make independent judgments regarding that care consistent with accepted professional standards. See Section 2.4.
C. A physical therapist shall not provide physical therapy services to a patient/client while is/her ability to do so safely is impaired.
D. A physical therapist shall exercise sound professional judgment based upon his/her knowledge, skill, education, training, and experience.
E. Upon accepting a patient/client for physical therapy services, a physical therapist shall be responsible for: the examination, evaluation, and diagnosis of that individual; the prognosis and intervention; re-examination and modification of the plan of care; and the maintenance of adequate records, including progress reports. A physical therapist shall establish the plan of care and shall provide and/or supervise and direct the appropriate interventions. See Section 2.4.
F. If the diagnostic process reveals findings that are outside the scope of the physical therapistýs knowledge, experience, or expertise, the physical therapist shall so inform the patient/client and refer to an appropriate practitioner.
G. When the patient has been referred from another practitioner, the physical therapist shall communicate the findings of the examination and evaluation, the diagnosis, the proposed intervention, and re-examination findings (as indicated) to the referring practitioner.
H. A physical therapist shall determine when a patient/client will no longer benefit from physical therapy services."
This information is available free of charge on the APTA website: www.apta.org As you can see, it is the responsibility of the physical therapist to discharge a patient once the patient has met all treatment goals and there is no reasonable expectation for reasonable improvement. The physical therapist may establish a maintenance program for the patient, which should be carried out under the auspices of nursing services.
Additionally, if a physical therapist within the state of Louisiana is convicted of fraud, the physical therapistsý license would be subject to Disciplinary Actions by the LSBPTE as outlined in the Rules and Regulations Section 327E on page 26.
The therapist may wish to review any appropriate documentation from the Medicare Manual for inpatient hospital and rehab services. The Board does not have jurisdiction over these areas. The physical therapist must exercise prudent judgment in the delivery of physical therapy services, the initiation, and completion of such services. It is hoped that this information helps to clarify any questions you may have in regards to the delivery of appropriate physical therapy services.
Chronic Pain Program w/Alternative Medicine Approach - Factual Scenario: We are currently in the process of developing a chronic pain program utilizing an alternative medicine approach. The program is under the medical direction of a physician who oversees the care of the individual patient. Currently, the care team consists of the physician, a certified athletic trainer, a certified counselor, and an exercise technician. We plan to include physical therapy in the near future. Question # 1: My question is if a PTA can work directly under a physician if physical therapy is not being billed separately, but the program is being billed at a predetermined rate in its entirety? If not, we plan to have the physical therapist evaluate the patient under the physician's order and then follow the practice act for supervision of the PT A. The program is a comprehensive program and is not billed or recognized by individual services. Question #2: The exercise technician performs the pool component of the program and may participate in the gym program. She is a certified aerobic and aquatics instructor. She also works as a physical therapy technician during other times of the day/week. The two programs are distinct programs, but currently are both housed in the physical therapy clinic. The program has a different cost center for employee's time and salary. Can the technician can work directly under the physician since these are two distinct programs and her services are not recognized or billed through physical therapy?
Board's Response to Question # 1: Pursuant to the Physical Therapy Practice Act and the Board's Rules, a PTA can not work directly under a physician as described in your factual scenario. There should be a physical therapy component of the pain management program. The physical therapy component should include the provision of services by the PT and the PTA. Again, a PTA can not work under a physician as set forth in your scenario. Pursuant to the Physical Therapy Practice Act and the Board's Rules, a PT is required to perform an evaluation to determine the need for physical therapy and establish a physical therapy treatment plan of care. Pursuant to Rule 305, the PT can then delegate parts of the physical therapy treatment plan to the PTA under requirements set forth in the Rule. Furthermore, it is necessary for the PT and PTA to comply with the requirements of supervision as set forth in Rule 321 and documentation requirements set forth in Rule 323.
Question #2: In carefully reviewing the scenario, it is obvious that the pain management program also contains a fitness component. The fitness part of the program is not required to be operated or supervised by the PT. If the fitness component is operated or performed separately, the supervision of the fitness instructor may be performed by a physician as long as it is not identified as physical therapy and not billed as physical therapy. As per your scenario, the Board understands that the health care system has failed these people. Furthermore, the instructor may not be referred to as a physical therapy technician or any type of nomenclature which references physical therapy.
CPT Codes - 97140 and 97124 - We are seeking clarification as to whether mobilization/manipulation is specific to soft tissue or bone (to the exclusion of the other). In other words, is it permissible for a massage, as performed by either a massage therapist or a physical therapist, to be included under manual therapy code 97140?
With regards to your question asking for clarification as to whether mobilization/manipulation is specific to soft tissue or bone (to the exclusion of the other), it is recommended that you contact your intermediary to answer this billing question. The interpretation of the codes is more properly addressed to this entity and is not generally within the purview of the Board.
The Board does wish to respond to your reference to a massage therapist performing a massage and billing such under a CPT Code, the Board takes the legal position that a massage therapist does not have the legal authority to represent himself as a physical therapist or bill for the services provided by a physical therapist in the healthcare arena. Stated differently, it is the Board's position that a massage therapist is not a healthcare provider and, therefore, can not legitimately bill third party payors, etc. pursuant to the CPT Codes.
Craniosacral Therapy - I have received information regarding the denial of a complaint's treatment of Craniosacral Therapy as experimental. I am asking for an opinion from the Louisiana Board of Physical Therapy Examiners as to whether they consider this treatment to be experimental?
The Louisiana State Board of Physical Therapy Examiners must respond that though research literature exists, it is not within the role of the Louisiana State Board of Physical Therapy Examiners to determine if Craniosacral Therapy is experimental or evidence based. Through its law, Rules and Regulations, the Louisiana State Board of Physical Therapy Examiners determines the scope of practice of Physical Therapy. The Board can report that there are components of Craniosacral Therapy, such as soft tissue mobilization and massage, which are within the scope of practice of physical therapy.
Direct Access - Patient diagnosis and subsequent treatment - With regards to the use of limited direct access in an outpatient private practice setting, what documentation is required as proof of previous diagnosis to treat the patient?
The patientýs diagnosis can be established by a number of methods, but must have been made by a Health Care Provider (physician) within the previous 90 days. Bills, copies of the physicians note stating the diagnosis, and insurance papers with associated diagnosis codes from the physicianýs office are all acceptable means of establishing a diagnosis.
Please note that once a plan of care has been established, this must be provided to the Health Care Provider within 15 days of initiation of treatment. Please refer to section 2410 D of the Louisiana Physical Therapy Practice Act for a full explanation.
DPT - Use of Title - 1) When is it appropriate for a physical therapist to use the title Doctor of Physical Therapy? What setting? Hospital? Inpatient Rehabilitation Center? Outpatient Clinic? 2) If a physical therapist can use this title in a hospital/rehab setting how should this individual identify himself or her self when first making contact with a patient?
In Rules and Regulations Subchapter B. Prohibitions, Section 307.B, the only designation for a Physical Therapist are the initials P.T. the rule as stated is:
B. A physical therapist shall use the letters "P.T." in connection with his name or place of business to denote licensure. A physical therapist assistant shall use the letters "P.T.A." in connection with his name to denote licensure. No person shall hold himself out to the public, an individual patient, a physician, dentist or podiatrist, or to any insurer or indemnity company or association or governmental authority as a physical therapist, physiotherapist or physical therapist assistant, nor shall any person directly or indirectly identify or designate himself as a physical therapist, physiotherapist, registered physical therapist, licensed physical therapist, physical therapist assistant, or licensed physical therapist assistant, nor use in connection with his name the letters, P.T., L.P.T., R.P.T., or P.T.A., or any other words, letters, abbreviations, insignias, or sign tending to indicate or imply that the person constitutes physical therapy, unless such person possesses a current license or temporary permit duly issued by the board.
It is appropriate for a therapist to list degree credentials preceding or after licensure designation of Physical Therapist.
Is it the Boards opinion that a physical therapist with a Doctorate Degree should identify themselves as a Physical Therapist. The individual should not allow themselves to be misinterpreted as a medical doctor by identifying themselves as a Doctor.
It is in the best interest of the public that physical therapist not allow themselves to be confused as a Medical Doctor by introducing themselves as Doctor to patients in the clinical arena. However, in the Academic Setting, the title of Doctor is of choice.
Eval and treat on the field - (1) Due to our new access to the well population and the fact that physical therapists can evaluate patients without a referral, can physical therapists work on the field (like at football games) without a doctor or an ATC present? (2) If the answer to the previous question is yes, what is a physical therapist's capacity with regard to evaluating and treating athletes on the field without a doctor present? For instance, can physical therapists only evaluate an injured athlete or can they perform treatment as well? (3) If physical therapists can treat on the field, how far can a physical therapist go with regards to the extent of the treatment? For instance, can a therapist perform first aid, taping, modalities, stretching on the field? (4) If a therapist cannot work on the field in the absence of a doctor or ATC, who does need to be present (MD, ATC, or both) in order for a therapist to work on the field?
(1) Please understand that since the inception of the Board's jurisdiction, being January 1, 1988, a physical therapist has been able to lawfully perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy without referral, but implementation of physical therapy treatment for a specific condition must be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry. Therefore, the recent promulgation of Rules 305 and 307 regarding preventative services does not impact a physical therapist's right to evaluate a patient without a referral. With regards to athletic events, the Board issued a Declaratory Statement published in the 1999 Newsletter addressing this issue. For your convenience, I will quote from the earlier Declaratory Statement as follows: The Board has determined that the pre-event procedures of massage, ice, superficial heat, stretching and warm-up exercises, and the post-event procedures of massage, ice, superficial heat, stretching and cool down exercises fall within the concept of consultative services and are in accordance with the Physical Therapy Practice Act and the Rules and Regulations promulgated by the Board and does not require a physician referral. However, post injury modalities such as electrical stimulation, prescriptive exercises, etc. shall not be performed without the referral or prescription from a physician. Furthermore, consultative services as referenced in the earlier Declaratory Statement could now be categorized as preventative services for the subject matter of this inquiry. Again, please be advised that once an injury has occurred any modalities would be considered physical therapy treatment and do require a referral or prescription from the appropriate health care provider in order to be rendered by a physical therapist.
(2) Please refer to Board's Response to Question #1 above. The physical therapist may perform CPR or first aid recognized by the American Red Cross with regards to an injured athlete, however, to implement physical therapy treatment, a physical therapist must first obtain a referral or prescription from the appropriate health care provider.
(3) Please refer to Board's Responses to Questions #1 and #2 above. A physical therapist may perform first aid, taping, and stretching on the field, however, modalities may not be performed without first obtaining a referral or prescription from a person licensed to practice medicine, surgery, dentistry or podiatry.
(4) Please refer to Board's Responses to Questions #1, #2 and #3 above. With regards to the specific question, in order for a physical therapist to "work on the field," which for the purposes of this response we will assume to mean the provision of physical therapy treatment, a person licensed to practice medicine, surgery, dentistry or podiatry must be on the field in order to diagnose the specific condition and provide a prescription or referral to the physical therapist.
FCE/Extender Assistance - The specific question was "can a licensed physical therapist who is performing a computerized functional capacity evaluation utilize an extender with direct supervision to assist him with data collection?"
The Board responded that a physical therapist can utilize physical therapy supportive personnel under direct supervision when performing a functional capacity evaluation to assist with data collection. The board continued by stating that "the physical therapist is solely responsible for the interpretation of any data collected and for making any recommendations to the physician, insurance company, etc." In reviewing the various scenarios with regards to supportive personnel roles in performing FCEs since the Board?s earlier statement, the Board will supplement its initial response as set forth below. At the outset, a physical therapist must be actively and directly involved in the performance of any evaluation, which includes an FCE. A physical therapist can not delegate any part of an evaluation to a tech. The tech may assist in patient set-up, positioning and recording data, however, a tech is prohibited from collecting data. During the collection of data, the physical therapist must be continuously observing the patient?s performance and continuously interpreting the patient?s behavior, body mechanics, limiting motion and monitoring safety concerns. Rule 305C promulgated by the Board states that it is prohibited for physical therapy supportive personnel to perform evaluations. Pursuant to Rule 305 there are two (2) types of supportive personnel, i.e., a physical therapist assistant and a tech. A tech is not legally permitted to do measurements. A physical therapist assistant may be able to do certain measurements as delegated by the physical therapist. The physical therapist assistant may assist in the testing if he has documented training and skills in goniometry and muscle testing, however, he also can not perform the entire data collection. It was not the Board's intent for its June 1, 2001 response to be interpreted to mean that an extender with direct supervision may perform the entirety of the data collection during the concept of "assisting a physical therapist while under direct supervision." Therefore, supportive personnel, such as a physical therapist assistant or tech. can not lawfully perform the entire computerized portion of an FCE. In comparison, support personnel may press the keyboard as the physical therapist is actually present, performing, and evaluating the patient's performance and efforts/body mechanics and physiologic responses. Therefore, in summary, a physical therapist cannot delegate to supportive personnel the "data collection and performance testing" which requires ongoing observation, the performance assessment of a patient's physiologic responses, efforts, consistency and clinical decision making. It is also the Board?s opinion that supportive personnel may not sign the FCE document and/or summary report as an evaluator. In the event. supportive personnel and/or a supervising physical therapist is performing or allowing FCEs to be performed in a manner which is inconsistent with this letter, such would be a violation of the Physical Therapy Practice Act and the Board's Rules.
Final visit - Home care - What is the Boards Rules regarding a PT or PTA making a final discharge visit to a home health care patient?
In review of Rule 321A (2) the physical therapist must: a) be readily accessible by beeper or mobile phone, b) evaluate and reestablish a written treatment plan on the patient prior to implementation of any treatment program; c) treat and reassess the patient on at least every 6th visit but not less than once per month; d) conduct, once weekly, a face to face patient care conference with each physical therapist assistant to review progress and modification of treatment programs for all patients, and e) assess the final treatment rendered to the patient at discharge and write the discharge summary.
The Board?s intent for 321A (e) was that in instances where the patient was discharged unexpectedly and the physical therapist assistant was the last clinician to treat the patient, the physical therapist would review the progress note written by the physical therapist assistant and the physical therapist would write the discharge summary. It is preferable, however, in planning scheduled home care, that the physical therapist actually make the final visit and evaluate the patient in order to write the discharge summary.
FMP - Skilled Treatment - Therapist were told by one physician, Medical Director of free standing short term rehab, to place these patients not appropriate on functional maintenance programs. What exactly is this in short term rehab? How do you charge and document for this? Is this really skilled treatment, when we are told to continue weight training/strengthening with patients that are exhibiting normal/functional strength?
The Board is of the opinion that no legitimate situation exists whereby a patient is placed on a maintenance program when involved in an inpatient rehab situation. In other words, when the patient no longer has realistic goals, there is no skill treatment and services are not billable as such. To do otherwise would be a violation of the Physical Therapy Practice Act and the Board's Rules, as well as other healthcare laws such as Medicare, etc.
Goals and FIM scores - When patients are admitted to a free standing short term rehab, s/p 20 years injury, noting they have been in/out of hospitals all their injured years, admitted to this facility with 6&7 FIM scores and therapist as well as physician recommend d/c administration doesn't allow d/c what should the therapist do? Patient is not progressing and goals are difficult to establish. Administrator says therapist need to "think out of the box and be creative." The FIM scores remain the same for 3-5 weeks as the administrator continues to not allow d/c of patient although at each staffing d/c is recommended and documented. Therapists are then criticized for their ethical recommendations.
Pursuant to the Physical Therapy Practice Act and the Board's Rules, a physical therapist is obligated to discharge a patient if there are no goals or reasonable expectations of gain. If the physical therapist exploits the relationship with the patient, the Board would investigate and sanction such physical therapist's license for violations of the Physical Therapy Practice Act and the Board's Rules. The Board also wishes to suggest that the facility should be careful with regards to what qualifies for inpatient rehab. The appropriate state governing authority should be consulted by the facility with regards to this issue. Additionally, "thinking out of the box and being creative" as suggested in the scenario could very well constitute violations of the Physical Therapy Practice Act and the Board's Rules as well as Medicare fraud, etc.
If a PT and technician conducted fitness and education classes for Parkinson patients in the community: - a) would a medical clearance serve as a PT referral for exercise? b) does the medical clearance need to specify physical therapy? If so, would this eliminate the ability for an aerobic instructor or technician to teach the class without a PT present?
The medical clearance does need to specify physical therapy if the P.T. is being billed for P.T. and the P.T. treatment is performed. This would eliminate the ability of an aerobic instructor or a technician to teach the class without a physical therapist present. You must first determine if it is a generic exercise/fitness program that you wish to initiate. If it is an exercise/fitness program, then it is not considered physical therapy and there would not be a need for a referral or prescription. Additionally, the exercise program could not be billed or identified as physical therapy, and would not require the presence of a P.T.. However, if it is physical therapy that is bring rendered then a prescription or referral is necessary as mandated by law. As you are aware, an unlicensed individual cannot render physical therapy treatment without a supervising physical therapist who is on the premises providing continuous supervision. Physical therapy, of course, can be identified as such and billed as physical therapy.
LTAC Patients D/C to nursing care - Therapists work in a short term rehab hospital, but are told that certain patients are to be treated as "long term care patients" although when therapists want to discharge just to nursing care they are told by administration that they can't. Is this legal?
No. the therapist is obligated by law to discharge a patient when goals are reached or there are no longer any realistic goals. What the administration is asking the therapists to do in your scenario could be construed as a violation of the Physical Therapy Practice Act and the Board's Rules, as well as other applicable healthcare laws.
Lymphedema Prevention - Question # 1: I have been approached by Mary Livingston, a social worker with Mary Bird Perkins Cancer Center in Baton Rouge, to provide assessments for women at risk with lymphedema. My proposed role is to identify women who need treatment and refer them to their physicians. Can I provide education to these women regarding lymphedema prevention? This information is not patient-specific, and is not based on evaluation findings. It would be the same for all clients. Question #2: Can I make recommendations for treatment? Question #3: Can I suggest that a compression garment might be helpful, or that a patient should contact her physician requesting physical or occupational therapy intervention for manual lymphatic drainage or compression bandaging?
Board's Response to Question #1: Pursuant to the Physical Therapy Practice Act, more particularly LSA R.S. 37:2410A, an initial evaluation or consultation of a screening nature to determine the need for physical therapy may be performed by a physical therapist, without a referral or prescription, but implementation of physical therapy treatment to individuals for their specific condition shall be based upon the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry. The Board is of the opinion that your proposed role as set forth in your inquiry is not a violation of the Physical Therapy Practice Act or the Board's Rules. Therefore, you may provide education regarding lymphedema prevention. However, please be advised that you can not implement physical therapy treatment without the proper referral or prescription.
Board's Response to Question #2: Yes, you can make recommendations for treatment, however, please refer to the Board's Response to Question #1 above.
Board's Response to Question #3: Please refer to the Board's Responses to Questions #1 and #2 above. In response to your specific question, the Board is of the opinion that you may suggest that a compression garment might be helpful or that a patient should contact her physician regarding physical or occupational therapy intervention for manual lymphatic drainage or compression bandaging. Such actions on your part are in the nature of education or consultation.
Please be advised that the Board's opinion set forth in this letter is limited to the factual scenario. In the event the facts are altered, the Board reserves the right to amend its opinion accordingly.
Manipulation - Does the Practice Act address manipulation?
LRS 37:2401. Definitions (1)(a) Practice of physical therapy is the health care profession practiced by a physical therapist licensed under this Chapter and means the holding out of one?s self to the public as a physical therapist and as being engaged in the business of, or the actual engagement in, the evaluation and treatment of any physical or medical condition to restore normal function of the neuro-muscular and skeletal system, relieve pain, or prevent disability by use of physical or mechanical means, including therapeutic exercise, mobilization passive manipulation, therapeutic modalities, and activities or devices for preventative, therapeutic, or medical purposes, and further shall include physical therapy evaluation, treatment planning, instruction, consultative services, and the supervision of physical therapy supportive personnel, including physical therapist assistants.
Additionally, the Board's Rules and Regulations in Section 305. Special Definitions; Practice of Physical Therapy, states:
Passive Manipulation - means manipulation or movement functions of the body or active effort on the part of the patient.
Manipulation/Physical Therapy - The Physical Therapy Practice Act, more particularly LSA R.S. 37:2401(1)1a) includes "passive manipulation" within the definition of the practice of Physical therapy. In response to the inquiry it is the Board's opinion that manipulation can be used in physical therapist documentation, represented as part of physical therapy and billed as physical therapy.
In comparison, the term "manipulation" is also used in the definition of th practice of chiropractic as set forth in the Chiropractic Practice Act, more particularly LSA R.S.37:2401 et seq. The Board is of the opinion that such concept or modality is common to both the chiropractic and the physical therapy industries.
Mobilization with Impulse - Can a PT use the term "mobilization with impulse?"
It is the Board's opinion that the use of the term "mobilization with impulse" does not constitute a violation of the Practice Act, or a violation of the Rules and Regulations of the Board. More specifically, Section 2422 of the Practice Act states:
"A physical therapist may not profess to provide "spinal manipulation" or "spinal adjustment," or use these terms."
The use of the term "mobilization with impulse" is not specifically addressed or prohibited in the Practice Act.
MT in PT setting - 1. Is a Licensed Massage Therapist able to perform only massage therapy or allowed to perform myofascial release techniques? 2. As a physical therapist in clinic, am I considered the massage therapist's supervisor? 3. Do I bill massage therapy and/or myofascial release, under my billing? 4. Paperwork wise, what sort of paperwork do I have to post or keep in the clinic, to have this massage therapist working under me? 5. Are there specific guidelines in the Physical Therapy constitution, if so, would you please fax these to my attention or where would I find this information on the Internet?
A physical therapist may use a massage therapist in a physical therapy clinic as support personnel more specifically as a physical therapy aide. The physical therapist must have a physicians order for physical therapy, and the physical therapist must evaluate the patient and set up a physical therapy treatment plan. A copy of the evaluation and treatment plan is sent to the referring physician. The physical therapist implements the treatment plan. At each visit, the physical therapist must reassess the patient's status and treat the patient. The physical therapist may delegate portions of the treatment to a physical therapist aide.
Neurosurgeon - PT Service - Question # 1: Can a neurosurgeon doctor operate on a patient and perform his own physical therapy on them? Question #2. Also, what license must he/she have or operate therapy services?
Board's Response to Question # 1:
The Physical Therapy Board is mandated by law to regulate the practice of physical therapy so as to protect the consuming public. The tools used by the Physical Therapy Board in discharging its function are the Physical Therapy Practice Act, LSA RS. 37:2401 et seq., and the Board's Rules. Pursuant to the Practice Act, only a licensed physical therapist or physical therapist assistant may perform "physical therapy" and bill for physical therapy services. However, as set forth in Section 2410B of the Practice Act, a person not licensed as a physical therapist or physical therapist assistant may be employed in a hospital, institution, clinic or physician's office to administer treatment under the direction and supervision of a licensed physician; however, the treatment administered shall not be identified as physical therapy and such persons administering such treatment shall not hold themselves out, nor be held by others as physical therapist or physical therapist assistants.
Therefore in response to your question, only a licensed physical therapist or physical therapist assistant may perform "physical therapy" and bill for such services. For an individual who is not licensed by the Physical Therapy Board to perform physical therapy and/or bill for physical therapy services is a violation of the Physical Therapy Practice Act. Doctors are regulated by the Louisiana State Board of Medical Examiners which licenses such individuals and regulates their practice. You may wish to contact that Board for license verification and to report his behavior. Certain modalities or procedures performed by physical therapists are similar, if not the same, as certain modalities performed by doctors. Pursuant to the law, the doctor may not refer to the modalities as "physical therapy" nor bill the modalities as such unless the person providing such services is a physical therapist licensed by the Physical Therapy Board or a physical therapist assistant properly supervised by a physical therapist licensed by the Physical Therapy Board.
Board's Response to Question #2:
Please refer to Board's response to Question #1 above.
New Graduate/Football Game Coverage - We have two new graduates working for us who are interested in covering football games with one of our local physicians and the school's athletic trainer. Are they able to attend a game under the rules of wellness with a temporary license? This would limit what they do to only basic first aide, if needed.
The Rules on preventative services, or wellness, became effective July 20, 2000. However, in carefully reviewing your inquiry, the Board is of the opinion that the Rule concerning preventative services does not apply to the factual scenario you have described. Furthermore, with regards to the two (2) physical therapist permittees set forth in your scenario, it is required that the supervising physical therapist also be present on the field pursuant to the supervision requirements for new graduates during the provision of physical therapy services.
Osteoporosis Prevention - Question # 1: Is osteoporosis prevention with regards to exercise prescription considered an area of wellness not requiring a physician's prescription? (i.e.) Can we see osteoporosis clients without a prescription and issue ex programs as well as educate in OP prevention, body mechanics, diet? Question #2: Also, can we do the above with the general population (i.e.) prevention and not dx with op?
Board's Response to Question # 1:
It appears that you are providing a one-on-one treatment to an osteoporosis patient by designing a customized exercise program, educational body mechanics and diet. It is the Board's opinion that such services constitute physical therapy treatment which would require the appropriate physician's order as set forth in the Physical Therapy Practice Act and the Board's Rules.
Board's Response to Question #2:
It has been the Board's position that the provision of group education to the general public on osteoporosis, general fitness and exercise, diet, etc. would be considered preventative services within the context of Board Rules 305 and 30ID. The provision of preventative services does not require a physician's order. It is also not legally permissible to bill preventative services as physical therapy treatments services to third party payors, such as insurance companies or Medicare. For your convenience, I enclose a copy of Rules 305 and 30ID.
Outpatient PT Records - Question # 1: I cannot remember how long we are supposed to keep out- patient P.T. records. (And does it matter if they were private payor Medicare patients?) Question #2: And is the date of destruction from the date of initial visit or the date of discharge?
Question # 1: The Board has previously responded to questino #1 with regards to records retention in Louisiana. These are the requirements that the Board implements in regulating the practice of physical therapy regardless of whether the patients are private payor Medicare. With regards to civil issues, it is suggested you contact a private attorney with regards to your rights and obligations concerning civil issues. For example, any rights that a minor has are generally suspended until one (1) year after he reaches the age of majority. The age of majority with regards to civil rights in Louisiana is eighteen (18) years of age. In other words, if a minor child has any claim against you in a civil matter; such claim may be brought by such minor until he reaches nineteen (19) years of age. Again, the Board is not providing you with any advice regarding the age minority issue, but rather suggesting that you might want to contact a private attorney for appropriate advice.
Question #2: The time periods required in the Records Retention Acts begin to run with the last date the patient is seen by you which in all probability will be the date of discharge.
Outside Therapy Treatment - Sterling Therapy is the therapy company that provides all therapy services to Avalon Place in Monroe, LA. Our staff is full time at the facility and handled all the facilities therapy for the residents. Recently we had a resident request to have an outside therapist come in after hours and after normal treatment to provide therapy. This concerns our PT Director on liability and providing services above the treatment he/she deems reasonable for the resident. I am contacting you on behalf of our PT Director (Jamie Floyd, PT). Jamie is under the opinion that allowing such treatment would conflict and create a secondary liability issue. Jamie and the facility administrator were hoping to confirm with the board if this extra treatment was acceptable.
While the Board has no prohibitions in its Rules and Regulations, it does not endorse such practice. In an effort to provide you with information to make a valid decision, all treatment must be upon referral from a physician, must be reasonable and necessary, and goals must be achievable within a general predictable amount of time.
You may benefit from consulting your facilities legal counsel and Risk Management in regards to medical-legal liabilities.
Patient d/c exercising in Clinic - Can patients who are discharged from physical therapy being able to continue exercising in the clinic for an hourly rate?
The Board has several concerns about such a program being offered P.T. clinic. First, it seems that the patient's perception would be that he would still be receiving treatment by the PT. If the patient continues to discuss problems with the therapist, it would be difficult for the patient to discern at what point therapy began and ended. Once a patient is discharged from therapy, his physical therapy goals should be met. The patient should be discharged on a home program or to a fitness center program under the direction of the fitness center staff. The Board cannot properly comment on your proposal without first reviewing the specifics. Upon completion of the program, it is requested that prior to your implementing the program, a copy of the plan be submitted to the Board for review and comment.
A second concern is that a patient may be discharged prematurely from therapy because the therapist knows that he will continue to see the patient. At this point, there would be no physicians orders or documentation related to the patient's care.
Peripheral Joint Mobilization - I am inquiring as to whether or not a PTA can perform peripheral joint mobilization. I see on the website that the Board was "conducting research" into the summer 2001 declaratory statements. I am the CCCE and CI of an outpatient clinic and need to know if the PTA students that come through can perform peripheral joint mobilization. They inform me that they are still trained in their program and that they have not been informed of their inability to perform such techniques.
On September 18, 2002, the Board made this Declaratory Statement o the issue of Passive Manipulation & Mobilization:
"The Board is of the opinion that it is prohibited for a physical therapist assistant or any other supportive personnel to perform passive manipulation or mobilization of the spine." It is also the Board's opinion that passive manipulation or mobilization of peripheral joints may be performed by licensed physical therapist assistants, but may not be delegated to any other supportive personnel.
Plan of Care changed after physician signature - If a PT writes a plan of care after an evaluation and the doctor signs the POC, can the PT then go back and change the same POC on a daily note without writing a new POC and getting a physicianýs signature approving the change? If the physiciansý signature is not required, can the PTA treat the patient with this change which is written only in the daily notes ý without the MD signature?
The board has opined this change can occur without obtaining signature of the physician. The PTA can then treat the patient with the changes documented.
PPS in Short Term Rehab - Is the new perspective pay system stating that 1 therapist is to treat 19 patients? How is this possible in short term rehab settings where the patient is required to receive 3 or more hours of therapy a day from P.T., O.T., and S.T.?
It is the Board's opinion that the Physical Therapy Practice Act and the Board's Rules do not provide a "physical therapist to patient" ratio. It is further the Board's understanding that the new perspective pay system does not address the "physical therapist to patient" ratio. It is recommended that you review the HCFA website with regards to this issue. Additionally, please be advised that he Board does scrutinize the quality of patient care provided by a physical therapist. Therefore, should the "physical therapist to patient" ratio be to such a degree that quality care provided to the patients is jeopardized; the Board would investigate and take action against the physical therapist for falling below the minimal standards of acceptable and prevailing physical therapy practice. In other words, the scenario raised by you could, by practical application, be in violation of the Practice Act and the Board's Rules, as well as other laws such as Medicare requirements.
Pre-Sport Physicals/Assessments - Question # 1: Is it permissible for a newly graduated, unlicensed physical therapist to perform orthopedic assessments for pre-sport physicals to include but not limited to manual muscle testing, range of motion, joint stability and scoliosis screenings? Question #2: Is it permissible for a PTA to perform the same screening procedures listed above if under the supervision of a PT? What level of supervision is required? Please list parameters.
Question #1: It is not permissible for a newly graduated, unlicensed PT to perform orthopedic assessments or any other physical therapy service prior to possessing a current, valid temporary permit or license issued by the Board. Furthermore, once the PT who has recently graduated receives a current, valid temporary permit, he must be under periodic supervision as required by Rule 153B as defined in Rule 305. Rule 305 defines periodic supervision as related to temporary permit holders who are graduates of APT A accredited programs to mean (1) daily face to face or phone communication between the supervising physical therapist and permit holders and (2) on premises observation of patient care in each of the permittee's practice settings, a minimum of two (2) hours per day with a minimum total of ten (10) hours per week total.
Once the temporary permit holder successfully passes the National Licensure Examination and is issued a license by the Board, there is no longer the requirement of periodic supervision as required by the Board's Rules and as discussed above.
Question #2: Pursuant to Board Rule 305, physical therapy supportive personnel, such as a PTA, can not perform evaluations which include screening procedures. The Board is of the opinion that a PTA may collect data, but the PT must complete the assessment, and is solely responsible for the interpretation of the data collected, and renders the decision with regards to whether or not a plan of care is required. Furthermore, the Board is of the opinion that during the collection of data by the PTA, the PT must be present.
PT Caseload - I am a PT currently working part-time for a nursing home. Our area manager told me about a concern regarding PT caseload. Here is an example: We, PTA and me, have a total of 10 patients which consists of three Part A Medicare patients being seen 5 times a week, 7 Part B Medicare patients all being seen 3 times a week except for one being seen 5 times. In our productivity report we have to count how many visits we do on a daily basis. Since we don't see all our patients on caseload everyday, the number of visits changes daily and is not constantly 10. Today, our area manager told us that we have to report 10 visits a day. I explained to him we don't see all the Part B Medicare patients everyday but 3 times a week. He insisted that we count 10 patients daily for the reason of report writing to the owner/management company of the nursing home. I told him my position that I will only count the patients that I have seen daily. My question is, is this legal and what is your opinion on this matter?
In carefully reviewing the inquiry, the Board is of the opinion that you may only report and/or bill for what is actually performed. Therefore, for you to falsely provide information in productivity report would violate the Physical Therapy Practice Act and the Board's Rules. More particularly, Section 2413A(7) provides that a PT or PTA may be sanctioned by the Board if found guilty of unprofessional conduct. Unprofessional conduct shall include departure from, or failure to conform to, the minimal standards of acceptable and prevailing physical therapy practice, in which proceeding actual injury to a patient need not be established.
Additionally, Rule 327E promulgated by the Board defines unprofessional conduct to include: 3. Making or participating in any communication, advertisement, or solicitation which is false, fraudulent, deceptive, misleading or unfair, or which contains a false, fraudulent, deceptive, misleading or unfair statement or claim; (Emphasis added.)
6. Abuse or exploitation of the physical therapy- provider-patient relationship for the purpose of securing personal compensation, gratification, or benefit unrelated to the provision of physical therapy services.
Furthermore, Section 2413 A(l) of the Practice Act also provides that a PT's and/or PTA's license may be suspended or revoked, or otherwise disciplined, upon proof that the licensee practiced physical therapy in violation of the Practice Act and the Board's Rules and Regulations. In summary, a PT and/or PTA may be sanctioned by the Board for reporting and/or billing for services not rendered, or falsely, reported. Additionally, you may not render any treatments which the patient's condition does not warrant for the purpose of meeting productivity standards.
PT Licensure Designation - On page 1 of the newsletter, there was an article titled, "Physical Therapy Licensure Designation." I want to make sure that I understand what you are saying in terms of how to list degree credentials. For someone with a doctor of physical therapy degree, they should list their license designation and degree credentials as follows: Jane Doe, P.T., DPT, followed by any other specialty certification or degree one may hold, is this correct?
Your example of listing Licensure status, degree attainment, then other credentials is correct. Remember that a PT should be sure to identify themselves as a PT to avoid misrepresentation.
Punch Biopsies - Is it within the scope of practice for a PT to perform punch biopsies?
It is of the opinion of the Board that punch biopsies are beyond the scope of practice of physical therapy, and therefore should not be performed by a physical therapist.
Reporting Violations - Who should violations be reported to and how should this be handled?
Violations should be reported to the Board, as well as to Medicare, the Louisiana Insurance Commissioner and the fraud and abuse section of HCFA for investigation.
Role of ATC in Clinic - What roll should ATC's play in a physical therapy clinic and should an ATC hold themselves out to patients as an ATC in the PT Clinic?
After researching and reviewing LA R.S. 40:1299.41., it is noted that ATC's are not defined as Health Care Providers. LA R.S. 40:1299.41 is listed below for your review.
A. As used in this Part:
(1) "Health Care provider" means a person, partnership, limited liability partnership, limited liability company, corporation, facility, or institution licensed by this state to provide health care or professional services as a physician, hospital, nursing home, community blood center, tissue bank, dentist, registered or licensed practical nurse or certified nurse assistant, ambulance service under circumstance in which the provisions of R.S. 40:1299.39 are not applicable, certified registered nurse anesthetist, nurse midwife, licensed midwife, pharmacist, optometrist, podiatrist, chiropractor, physical therapist, occupational therapist, psychologist, social worker, licensed professional counselor, or any other nonprofit facility considered tax exempt under section 501(c)(3), Internal Review Code, pursuant to the 26 U.S.C. 501(c)(3), for the diagnosis and treatment of cancer or cancer-related diseases, whether or not such a facility is required to be licensed by this state, or any professional corporation a health care provider is authorized to form under the provisions of Title 12 of the Louisiana State Revised Statutes of 1950, or any partnership, limited liability partnership, limited liability company, or corporation whose business is conducted principally by health care providers, or an officer, employee, partner, member, shareholder, or agency thereof acting in the course and scope of his employment.
Additionally, LA R.S. 37:3302 (the Athletic Trainers law) defines ATC as "carrying out the practice of prevention, emergency management, and physical rehabilitation of injuries incurred by Athletes at any educational institution, professional athletic organization, and any athletes participating in athletic competition or events sponsored by these organizations or other board sanctioned organization."
Given the above information, it is the opinion of the LSBPTE that ATCs are not listed as "health care providers" in the state of Louisiana. Therefore, when an ATC is employed within a physical therapy clinic and providing care per a P.T. Treatment Plan under supervision of a licensed physical therapist, they are functioning as and are identified as a physical therapy aide/technician. The appropriate identification by nametag or badge of the ATC as a physical therapy aide/technician will avoid the misrepresentation of ATC's as a health care provider.
The care provided by an individual employed in this role in a physical therapy clinic is subject to all supervision requirements, is unable to perform the entirety of any treatment session. Additionally, the ATC providing treatment in the PT clinic under the supervision of a licensed PT may not document patient care provide; see 323 Documentation Standards in Rules and Regulations on page 24.
Continuous supervision is required by any individual functioning in the role of a PT Aide/Technician as specified in 321 Supervision Requirements, C. Physical Therapy Aide/Technician (page 23 of the Rules and Regulations). 305 Special Definition: Practice of Physical Therapy defines Continuous Supervision as the "responsible, continuous, on-the-premises observation and supervision by a licensed physical therapy aide/technician." Physical Therapy Aide/Technician is defined "as a worker not licensed by this Board who functions in a Physical Therapy Clinic, Department or Business and assists with preparation of the patients for treatment and with limited patient care."
More specifically, 305 A Physical Therapy Aide/Technician c. outlines "the level of responsibility assigned to physical therapy supportive personnel is at the discretion of the physical therapist, who is ultimately responsible for the acts or omissions of these individuals. Supportive personnel may perform only those functions for which they have documented training and skills. The prohibitions for physical therapy supportive personnel shall include, but not be limited to, interpretation or referrals; performance of evaluations; initiation or adjustment of treatment programs; assumption of the responsibility for planning patient care; or any other matters as determined by the board. The physical therapist shall only delegate portions of the treatment session to an aide/technician only after the therapist has assessed the patient's status."
Specialized Wheelchair - I have a question regarding the responsibility we as PTs have when ordering specialized wheelchairs for patients. In my setting in Opelousas, we often order specialized wheelchairs for patients with the help of the local D.M.E. vendors. They usually do all the paperwork as far as submitting our requests to Medicare/Medicaid or Private Insurance for approval of these chairs. A lot of the time, these patients are discharged prior to receiving their wheelchairs. My question is as follows: Do we have a legal or ethical obligation to follow-up to see if these patients have received their chairs and make sure they fit properly after these patients have been discharged, or does it fall into the hands of the D.M.E. vendors that we use?
The Board is mandated by law to regulate the practice of physical therapy in Louisiana to protect the consuming public. The basic tools used by the Board in discharging its function are the Physical Therapy Practice Act and the Board's Rules. Pursuant to the Practice Act and the Board's Rules, a PT is under no obligation to follow-up after the discharge of a patient from physical therapy unless the patient calls with a problem which is appropriate for the PT to address, concerning the provision of physical therapy services. At this time the PT re-establishes the provider-patient relationship with the patient, the requirements of the Physical Therapy Practice Act and the Board's Rules apply with regards to the standard of care.
Spinal Adjustments - Can Physical Therapists perform spinal adjustments and advertise such service pursuant to the Physical Therapy Act of Louisiana?
The Board carefully reviewed your letter at its November 18, 1999 meeting and has directed me to respond accordingly. Pursuant to the Physical Therapy Practice Act of Louisiana, more particularly LSA R.S. 37:2401, the practice of physical therapy includes manipulation. Pursuant to the scope of the practice of physical therapy as defined by the Physical Therapy Practice Act and the Board?s Rules, spinal mobilization and manipulation are part of a physical therapy treatment plan. The term spinal adjustment is not terminology typically used in the practice of physical therapy. If the concept is synonymous, such modality is within the scope of the practice of physical therapy in Louisiana, and as such, a physical therapist may lawfully advertise the provision of such a service.
Spinal Manipulation - Question 1: I am writing the Board to inquire about the legality of spinal manipulation in the field of physical therapy in the State of Louisiana. I am currently enrolled in the Ola Grimsby Institute's Part 11 residency which trains in spinal manipulations among other things. I do have a copy of the current Practice Act and the guide to P.T. practice. I have also contacted Dave Pariser, the President of the LPTA regarding this. I would, however, like any and all information regarding the legality of this treatment technique in our state. Will you please give you interpretation of the law regarding this question? Question 2: Also, are you aware of any opposition to the practice of manipulation? Question 3: That is, are the chiropractors planning any further opposition to our profession practicing manipulation or the use of particular terminology in our progress notes regarding manipulation, adjustments, impulses, positional faults?
Answer 1: The Board carefully reviewed you inquiry at its January 25, 2001, meeting and has directed me to respond accordingly. It is the Board'd opinion that spinal manipulation is within the scope of the practice of physical therapy as set forth in the Physical Therapy Practice Act and the Board's Rules. Please understand that spinal manipulation may only be performed by a physical therapist licensed by the Board and is not a procedure which can be administered by a physical therapist assistant.
Answer 2: The Board is unaware of any actual, current opposition to this practice; however, it may be assumed that if any opposition were asserted it would be from the chiropractic group and other somewhat related industries.
Answer 3: It is unknown at present as to what the chiropractors or any other group may be planning. Please be advised that the Regular Session in 2001 which begins in early April is a non-fiscal year. In other words, the upcoming Legislative Session may involve proposed amendments to existing Practice Acts and/or propose enactments of new law with regards to this topic. It is strongly suggested that you contact the Louisiana Physical Therapy Association with regards to these legislative activities. Additionally, should you hear of any proposed Bills, please do not hesitate to contact the Board office with such information.
Spinal Mobilization/Manipulation - Can a physical therapist assistant perform spinal and/or peripheral passive joint mobilizations and joint manipulations?
The Board is of the opinion that it is prohibited for a physical therapist assistant to perform spinal mobilizations and spinal manipulations. The Board is in the process of conducting research with regards to peripheral joint mobilizations and manipulations.
Staples - Stitches - In homecare, are physical therapists able to pull staples or stitches?
Pursuant to the Physical Therapy Practice Act, LSA R.S. 37:2410 et seq., and the Board's Rules, it is within the scope of practice of physical therapy for a PT to pull staples or stitches. A PT may perform an initial evaluation or consultation to determine need for physical therapy and to establish a physical therapy treatment plan, however, the implementation of physical therapy treatment to a patient for his specific condition shall be based on the prescriptions or referral of the appropriate licensed healthcare provider. Therefore, the removal of staples and/or stitches by a PT can be done pursuant to a prescription or referral from a person licensed to practice medicine, surgery, dentistry or podiatry.
Transporting Patients in Corporate Vehicle - Who should judge if a facility transport vehicle is safe to operate? When therapists recommend vehicle straps on w/c to hold stabilized in transport vans are not safe, administration doesn't repair appropriately, but therapist is told that van is appropriate to transport patients. Transport vehicle is not safe, what should be done?
The therapist is responsible for the safety of patients while in his care. If you knowingly place a patient in an unsafe situation and the patient is injured you could be in violation of minimal standards of acceptable and prevailing practice as well as liable from a malpractice standpoint. It is recommended that with regards to the safety of the transport vehicle, any concerns should be reported to the Louisiana Department of Public Safety as well as your own quality assurance department. It is also suggested that the risk management department of your facilities liability insurance carrier also be notified.
Unable to progress with Treatment - If a patient is not capable of retaining compensatory strategies from one day to the next and therefore unable to progress with treatment, should they be kept in a short term rehab until their payor source is exhausted?
In response, if there are no goals or no progress towards established goals, then the patient should not be kept in short term rehab until their payor source is exhausted as set forth in the question. To do otherwise would be a violation of the Physical Therapy Practice Act and the Board's Rules, as well as other applicable healthcare laws.
