Christy Ciesla is a doctor of physical therapy at Rhode Island Hospital and The Miriam Hospital and coordinates women’s health physical services at the Miriam Hospital. She serves as vice chair of the Rhode Island Women and Men’s Health physical therapy Special Interest Group. She is also a credentialed clinical instructor and often mentors other physical therapists and Brown medical residents interested in pelvic floor and pelvic health.
PBN: Are you seeing changes in the way insurance handles physical therapy billing since Obamacare was introduced?
CIESLA: Personally, I have not seen many significant changes as of yet. Some insurance providers are beginning to suggest that we become more involved in outcome-driven care. For example, we are being increasingly called to justify our services through the use of objective, validated outcome measures to provide evidence of patient progress with our services. This could be progress in functional capabilities, objective measurements (strength, range of motion, endurance), or simply the patient’s subjective perception of improvement.
PBN: What makes sense, if anything, in the way that physical therapy has traditionally been billed?
CIESLA: Physical therapy has always been billed utilizing specific procedure codes. We document what we do during each visit by utilizing a code for each modality we may use with the patient. These codes are also time-based. One “unit” is considered anything we do for 8 or more minutes. For example, if we see a patient for 23 minutes and do manual therapy with that patient, we would bill the procedure code, 97140 (manual therapy), for 2 units.
In the area that I work (pelvic PT), these procedure codes are outdated and limited, and no longer make sense. Physical therapy is a doctorate level profession. So much of what we do does not involve hands-on work with the patient. I can have an extremely involved treatment session with limited patient contact, and patient outcomes could be significantly improved from that visit alone. Time spent on specific procedures is often difficult to provide to payers. Instead, a physician-based fee schedule would work much better, e.g., comprehensive visit, limited visit, etc.
PBN: What would you like to see handled differently – do you see the ACA as an opportunity for some positive changes?
CIESLA: I believe that the ACA has the potential to help us make big changes in our profession for the better. If you have a good work ethic and take your work seriously, and have good patient compliance, outcome-driven payment is the way to go. However, there needs to be some accounting for limitations such as patient compliance, patient population, and types of services that can drive outcomes down.
PBN: Your practice recently changed to a hospital setting; how has that changed what you can do?
In many ways, my practice has grown. I work more closely with the physicians and have access to pertinent medical records and better interdisciplinary communication. I also find that the hospital accepts most insurance, and the patients are pleased with the cleanliness of the facilities and the professionalism of the environment.
However, there are limitations in the hospital for physical therapists. In Rhode Island, physical therapists with more than 5 years of experience can evaluate a patient without a physician referral, and treat them for 90 days before they should refer the patient for a physician consultation (Direct Access). I utilized this often in private practice, and many of the insurance providers did not require a physician referral for the patient to be seen. After 15 years, I feel confident that I can recognize the signs of something that goes beyond my practice scope and refer out accordingly. Unfortunately, the limitations that the Joint Commission places on us will not allow us to see patients without a referral.
Also, the fee schedule for hospitals is much higher than in private practice. Having access to state-of-the-art facilities is costly. This has significantly limited my self-pay population, and patients with high deductibles. In private practice, we had more autonomy in designating a self-pay rate for uninsured or underinsured patients. Unfortunately, the hospital has to abide by insurance contracts and has to charge patients insurance rates. I have lost some patients due to the inability to afford these rates.
That said, however, I have seen a wonderful influx of community free service that the hospital does provides to patients who cannot afford services without insurance.
I suppose there are good and bad to both. Either way, I am overall happy to be where I am and proud to be a part of Lifespan.
PBN: Do you find that doctors are open to learning from physical therapists, generally, and specifically with respect to pelvic physical therapy?
CIESLA: Tough question and one that I speak about often. Overall, in my specialization, I feel that I get more respect from my referral sources than ever before. I maintain open relationships with them, and I like to think that I have taught them a thing or two. I have also treated a fair number of physicians, and have found that, as intelligent as many of them are, they know very little about the area of the body that I treat. In fact, even urologists and OB-gyns are not trained in pelvic floor function and dysfunction in the ways that PT’s are. I imagine this holds true in all areas of physical therapy.
I recently had a patient who underwent a prostatectomy several years ago who was leaking a significant amount of urine. He told me that his urologist told him that I should not be training him to recruit his deep abdominal muscles, but that he should be using his anal sphincter only. I then had to explain that the transverse abdominus has fascial connections to the pelvic floor and that you cannot do a Kegel exercise without recruiting it. Therefore, utilizing this muscle during activities can diminish stress on the surgical site and help to close the sphincters that maintain continence during functional activities. If the patient had lost faith in me, he would have had a poor outcome with physical therapy.
In a very specialized health care world, all providers should respect their scope of practice, and, especially, the scope of others. I would never critique a surgeon’s skills. I don’t expect any referral source to second-guess an approach that I have spent years developing expertise with. Physical therapy has come a long way, but we have a long way to go as a profession to gain the full respect we deserve. We are still often viewed as professionals who provide range of motion and exercise programs only. As I said before, PT is a doctorate profession. We need to uphold those standards. I suppose my patients’ outcomes speak for themselves.
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