The Small Patient Practice, by J.G. Colburn, Colorado Springs, CO: Three Leaf Press; 2011, softcover, 126 pp, ISBN: 978-0-983-50330-9, $37.95.
The author provides a guidebook for beginning a solo practice that caters to children. Colburn states she wants to take the mystery out of medical insurance billing and coding for Pediatric Physical Therapists (PTs), Occupational Therapists (OTs), and Speech Language Pathologists (SLPs). Although her examples focus on pediatric clientele, any practitioner would find the easy step-by-step guidance useful for billing. This easy-to-read book contains a short introduction, 11 chapters, acknowledgments, 12 appendices, a glossary and definitions of acronyms, and an index. It is written as if Colburn was sitting next to the reader and talking through each section.
In the introduction, the author explains her background and states she uses her accumulated knowledge to simplify the process of medical documentation, billing, and coding. In Chapter 1, A medical billing and documentation guide for pediatric rehabilitation therapists, Colburn begins the process by outlining the steps needed to get paid. The rest of her chapters, explain each of the steps in more detail. After reading Chapter 1, the reader will come away with the knowledge necessary to make the decision to start a small home-based business or not, from the perspective of reimbursement. Colburn makes it clear that each practitioner needs to be a qualified PT, OT, or SLP and needs to know the state laws for the state in which the practice will occur. Chapter 1 also clarifies the importance of Health Insurance Portability and Accountability Act standards and electronic billing to reimbursement policies, which has made it easier for the practitioner to learn 1 set of billing and reimbursement rules.
Chapter 2, Understand your patient's healthcare plan, explains the need to contact a potential patient's insurance company before starting services. Specific information needed by the practitioner before contacting the insurance company is provided along with a sample form (Appendix A: Intake Insurance Information). Specific questions to ask the insurance company representative are also provided with a sample documentation form (Appendix B: Patient Insurance Plan Data). The author offers practical advice about what not to state in this phone contact. Specifically, Colburn helps the reader make the clear distinction about providing outpatient care in a patient's home versus being a Home Healthcare Agency. The rest of this chapter presents the pros and cons of network service provision.
In Chapter 3, Required and Recommended Elements of a Patient Record File, Colburn identifies documents that are necessary and suggested to compile in each patient's file. Important requirements are the Signed Permission to Bill and Permission for the Payer to Pay the Practitioner Directly (Appendix C) and Acknowledgement of Receipt of Privacy Notice (Appendix D). Recommended documentations include all contact information, summary of health insurance policy requirements, and records of payments.
Chapter 4, Documentation, begins with the information that “most healthcare insurance payers are familiar with and have adopted or defer to the CMS Manual ...for service provision and this includes documentation” (p25). Colburn provides the Web address for this manual specifically citing chapter and sections for relevant documentation guidelines. Throughout this chapter, the author clarifies the differences in terminology, but commonality of intent between Medicare and typical language used by a pediatric therapist such as “certification” versus physician referral. She succinctly explains the need for justification for services that are medically necessary making the distinction from the justification for services provided in schools or Early Intervention. In the section on Required Elements of the Evaluation (Appendix E), Colburn's first point is that the identified treatment diagnosis/disorder is the key to whether a payer will cover services. She explains that International Classification of Diseases, Revision 9 (ICD-9), codes (condition descriptors such as “difficulty walking” or “muscle weakness”) are the treatment diagnoses/disorders. Colburn makes it clear, through examples, that this medical evaluation must be problem focused. The rest of this chapter notes the differences among a reevaluation, progress report, treatment note (Appendix F), and discharge note.
Chapter 5, Billing for Outpatient Pediatric Rehabilitation Services, is a step-by-step guide to completing the claim form CMS-1500 (Appendix G). This is the form or its slight variations used for all billing. Colburn begins this chapter with practical advice by identifying the Web site where this form can be obtained free of charge and notes that many insurance payers provide online access to their forms free of charge. The rest of the chapter is precise directions for filling out each box (identified by number) on the form. If the reader feels more information is needed, the Web address and specific page that offers more detailed instructions for filling out the form are included in this section.
In Chapter 6, Coding for Diagnoses and Services, the purpose of the ICD-9 codes is explained in more detail. The beginning of this chapter supplies a Web address for finding additional ICD-9 codes, but offers specific examples that often apply to pediatric clients. The next section provides examples for billing of timed treatments using Current Procedural Terminology (CPT) codes. Colburn identifies common CPT codes used by PTs, OTs, and SLPs, but notes that a practitioner may need to gain access to a modified CPT codebook for more information. After providing the explanation from the Department of Health and Human Services of the billing rules, sometimes called the Rule of 8, Colburn provides 5 different examples of appropriate billing based on the number of minutes of service provided. Additional information in this chapter includes how to use code modifiers and what to do to avoid denials and accusations of fraud.
Chapter 7, Reading the Explanation of Benefits, explains the purpose of this document, which should accompany each payment from the health care payer. Colburn explains common terms used in the explanation of benefits such as “amount allowed,” “amount paid,” “amount billed,” and coinsurance versus copayment. This chapter ends with practical advice about a common mistake seen on the explanation of benefits and how to resolve this issue.
In Chapter 8, Billing the Patient, Colburn clarifies why each patient must be billed, stresses the consistency in billing per code, suggests pros and cons of a cash-based practice, and provides a format for the patient's bill (Appendix J).
Chapter 9, Wording for Medical Records, emphasizes the importance of communication in writing. It begins with words or phrases, such as sensory integration, that are red flags to medical insurance companies for nonpayment. Colburn provides multiple examples of correct wording that explain problems addressed by PTs, OTs, or SLPs including care for children with progressive disorders.
Chapter 10, titled Troubleshooting, presents information about justification of adaptive equipment, restricted number of visits, payment denials, overpayments, and insufficient payments. In Chapter 11, Your Office and Your Practice, Colburn offers suggestions for equipment and scheduling along with advice about no shows. She gives additional guidance about outlining parental responsibilities related to services (Appendices K and L). Colburn completes this chapter by discussing the topic of paying yourself.
In addition to the appendices noted earlier there is an example of a letter that may be sent to the health care payer regarding incorrect processing of a claim (Appendix H) and the warning from the US Department of Health and Human Services regarding waiver of payments (Appendix J). The practitioner will find all forms included in the appendices necessary and useful to organize practice.
This guidebook assists any pediatric rehabilitation therapist, who wants a home-based business, by identifying the steps to becoming a solo practitioner with emphasis on the processes for medical billing and coding. Its ease of readability makes it a suitable book for students learning the processes of medical billing, coding, along with terms and acronyms. Even though the focus was on a pediatric practice, any practitioner who wishes to begin billing for services would find it a useful reference.
Karen M. Kott, PT, PhD
Old Dominion University
The Cowden Preautism Observation Inventory: With Effective Intervention Activities for Sensory Motor Stimulation and Joint Attention, by Jo E. Cowden, PhD, Springfield, IL: Charles C. Thomas Publisher Ltd.; 2011, paperback, 206 pp, 98 illustrations, ISBN: 978-0-398-08643-5, $43.95.
The primary purpose of this book is to increase awareness of behaviors that children may possess before a diagnosis of autism so that intervention may begin as early as possible. To achieve this, the author (Cowden) developed the Cowden Preautism Observation Inventory (CPAOI) for use with infants up to 12 months. Cowden's second purpose in writing this book was to provide intervention suggestions for children suspected or diagnosed with autism. The author recommends the book for both parents and professionals.
Comprised of 11 short chapters, this book can be read fairly quickly. Each chapter is broken down into sections with numerous photographs to illustrate key points. A short appendix on infant neurology and a list of suggested readings is included. In addition, a CD-ROM is provided as a supplement for a printable version of the CPAOI.
Chapter 1, Understanding Autism, gives the author's definition of preautism and presents the CPAOI in full. The CPAOI is a criterion-based observational checklist containing 166 items that parents complete. It is not a standardized tool or meant for diagnosis. The items are split into 9 categories including: cognition/prelanguage, social-communicative play, sensory motor skills (including the visual system), auditory system, tactile system, vestibular-kinesthetic systems, central nervous system maturity and righting reactions, developmental movements, and fine motor. Although the checklist does provide many appropriate items for observation/assessment for children at risk of autism, many of them are not appropriate for parental assessment such as reflexes and muscle tone.
Chapter 2, Brain Plasticity, is a brief introduction to the topic of neuroplasticity highlighting the potential for change within the nervous system. The author postulates the brain reorganizes itself in response to multiple variables such as sensory stimulation, new experiences, and substitution. The importance of early intervention for children with autism is emphasized to maximize potential for change.
Chapters 3 through 5 are focused on the clinical manifestations of “preautism.” Chapter 3 presents a discussion of possible mechanisms, causes, and associated medical conditions that may be seen in children with autism such as abnormal brain development, prematurity and low birth weight, birth asphyxia, respiratory distress syndrome, hyperbilirubinemia, seizures, and moebius mouth. Caution should be taken when reading this as it may lead readers to assume that all infants born prematurely or with medical complications may develop autism. Chapter 4 reviews the signs and symptoms the author lists as “behaviors that may be eventually used for diagnosis of infants with preautism.” These behaviors are items on the CPAOI checklist. Again, caution is suggested as parents (or health professionals other than physicians) cannot make the diagnosis of autism. Chapter 5 provides a brief overview of visual, auditory, tactile, vestibular, and kinesthetic systems and their possible relationship to preautism.
Chapters 6 through 11 are focused on intervention strategies. Chapter 6 lists suggested ideas for intervention strategies concerning behavior management. It is a very brief glimpse into a complicated issue that many children with autism face. Chapter 7 gives recommendations for intervention strategies for areas such as muscle tone, reflexes, facilitation of movements, equilibrium reactions, tactile stimulation for warm-up, relaxation, flexibility, and coordination of stability and mobility. The author states the interventions should be chosen only after developmental assessment, or using the CPAOI. Chapter 8 gives general information about sensory systems (tactile, vestibular, visual, auditory, kinesthetic), followed by a list of activities to complete for each system. Unfortunately, the chapter does not explain how a thorough assessment of sensory processing by trained professionals using proper assessment tools must take place before choosing interventions, making this potentially confusing for parents who may pick inappropriate activities for their child. Chapter 9 gives a summary of the work the author has done with her therapeutic riding program over the last 25 years. She believes therapeutic horseback riding is one of the best ways to build joint attention, social communication, and sensory motor skills for children with preautism and autism. Chapter 10 was intended to provide exercises and activities to improve/address low tone. Instead, it gives more of a focus on muscle strengthening and motor development. While many of the descriptions and activities are appropriate for young children, they do not necessarily address the problem of low tone. The reader is cautioned to remember that muscle strength and muscle tone are not the same. Chapter 11, Activities for Reflex Integration and Decreasing Muscle Tone, also leads the reader to think that this chapter will provide interventions that will address hypertonicity. Again, although there are many good pictures and descriptions of activities, they focus more on strengthening and development. Likewise, the chapter proposes activities that will facilitate reflex integration. There is no evidence provided to support this concept.
The author brings up a very good point regarding early assessment of autism. Very often there are signs and symptoms seen in infants who are later diagnosed with autism. Her book encourages parents to be good observers of these possible indicators of autism to advocate for early diagnosis and treatment and provides a checklist (CPAOI) of these behaviors. Several things gave me great concern, however, when reading this book. First, parents are not trained professionals and do not have the education and experience to assess reflexes, muscle tone, or developmental skills, or in designing a plan of care. Throughout the book, they are encouraged in some way to do this. Second, there is a lack of evidence to support many of the interventions described. These activities/exercises are not “one size fits all,” which is what many parents may assume when reading the book. Finally, the use of the CPAOI should be limited as it is a new tool that has not gone through rigorous testing for validity and reliability.
In conclusion, whereas this book does have some valid ideas and information, its use should be limited and parents should be cautioned to avoid making a diagnosis and developing a plan of care that may not be appropriate for their child.
Deborah Nervik, PT, MHS, DPT, DHS, PCS
Franklin Pierce University, Concord, New Hampshire