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Writing Functional Therapy Goals

March 11, 2014 9 Comments

Writing Functional Therapy GoalsAre you writing functional therapy goals?  I guess I better take that a step back and ask if you are accurately writing functional therapy goals for a Medicare Plan of Care.   Required elements of the Medicare Plan of care include 1) Diagnoses; 2) Long term treatment goals, and 3) Type, amount, duration and frequency of therapy services.

According to the Medicare documentation requirements detailed in the Medicare Benefits Policy Manual, Chapter 15, Section 220.1.2 (B)

Goals should be measurable and pertain to identified functional impairments. When episodes in the setting are short, measurable goals may not be achievable; documentation should state the clinical reasons progress cannot be shown. The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims-based functional reporting, using non-payable G-codes and severity modifiers, for services furnished on or after January 1, 2013.

Medicare also describes other elements as optional, but considered good practice:  short term goals, goals and duration for the current episode of care, specific treatment interventions, procedures, modalities or techniques and the amount of each.   Short term goals are good bridges to long term outcome goals, and help guide progress,  particularly as impairment goals wherein objective tests and measurements related to strength, range of motion and endurance are concerned.  However, increased strength is not a functional outcome goals, nor is increased range of motion.  However to get to a functional outcome, it is necessary to progress through the impairments preventing function.

Tips for writing functional therapy goals

Let’s take a look at writing functional therapy goals.  You are working with a patient that has had a total knee replacement, and you are following a protocol for progressing the patient through a post-knee therapy program, but have you defined what the functional outcome is (remember this has to tie in to functional limitation reporting)?  A good place to start is the patient’s prior level of function.  For example, “patient could previously go from stand to sit and sit to stand when using a normal commode in their home”.  The current level of function as this patient presents for post-knee replacement therapy at your clinic might look like this: “Currently able to go from stand to sit with max assistance, and unable to go from sit to stand without use of seat raiser and max assist”.  Are you beginning to get the picture?  Short term goals are likely to address range of motion and weight bearing, in other words, these are incremental impairment goals that when achieved will assist in the patient achieving the long term functional outcome goal of “Ability to go from stand to sit and sit to stand in order to use the commode”.  The function is sit to stand and stand to sit, and the outcome is the ability to simply “use the commode”.

There are plenty of other activities to select that represent a functional outcome – very often I see “ability to stand at the kitchen counter to prepare a light meal”, or “ability to ascend and descend 5 steps at the entrance of the home”.  These outcomes are functional.  There are plenty of functional activities that a patient will want to achieve following therapy – better golf swing, bend down to do gardening, get up from Lazy-Boy recliner, and so forth.  But let’s face it, there is nothing like the ability to use the commode to help describe the medical necessity of therapy.  Amen.

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (9)

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  1. I appreciate the potty humor in this blog suggesting therapists consider the medical necessity of toilet transfers as perhaps an important functional goal to be measured, coded, tracked and reported. With tongue in cheek, removing this last barrier to personal privacy is one I will not support! In all my 13+ years of providing home outpatient physical therapy under Medicare Part B, I have never received a referral for toilet retraining. I have never specifically listed toilet transfers as a functional goal because I consider myself a different kind of “movement” specialist and the fast solution to this potty problem has always been DME. Against the backdrop of Functional G-code Reporting becoming a “constipated” claim processing problem as noted elsewhere, I feel some “relief” in knowing the ACA mandates that medical practitoners determine if DME equipment is medically needed. So, I will happily continue to refrain from getting involved in potty diagnostics, but admittedly I am still really “pissed” that I must give up my “free” time to manage manutiae and address claims denied in error because of ongoing data processing problems related to mind-numbing layers of computerized bureaucracy!

  2. I have to say that toileting is an important functional task for patients. I mean, you don’t want to just leave them “hanging there.” In this case, “movement” is vital, and “keeping things moving” is part of our job. Sometimes the “urge to move” comes up quickly, and we don’t want patients to feel like they’re moving “upstream.”

  3. Tracy Sher says:

    Yes… Amen to the “ability to use the commode”. All well-stated, Nancy!
    Pelvic Physical Therapist and a Commander of Commodes – Tracy

  4. Yes, Yes….but let us use language to “elevate” and broaden our profession’s value and impact on patients’ quality of life by not focusing on the toilet…although I can’t help but smile while thinking of the word “crap” when it comes to Functional G-code Reporting!

    This is what I mean in the 2 examples of functional outcome goals:
    1) This woman will develop sufficient limb strength, balance control and problem-solving skills to self-manage in-home transfers with minimal caregiver cues in order to transfer from various seated environments (i.e. bedroom, bathroom, wheelchair, stairlift chair, car) that range in height (i.e. 15″ -22″) and that necessitate the use of different upper extremity push/pull strategies and supportive equipment (e.g. bedrail, chair armrests, grab bars, walker, HandyBar, Car Caddy).
    2) Function In Sitting Test score will improve 10 points to 48/56.

    I  prefer to use “#2” to satisfy those reviewers who may have tired eyes. Full disclosure: I am a contributing author listed on a soon-to-be published article on the FIST.

  5. Cheryl Anderson says:

    Hi Lisa M,

    I have a question regarding your 1st STG. You appear to be addressing several impairments (weakness, decreased balance and problem solving skills) and under several conditions. What happens if the patient meets goals in some circumstances but not others?????

    I agree with and like goal #2.


  6. Hi Cheryl,
    All my patients are medically complex with multiple impairments affecting their function, contributing to their disabilities and potentially exacerbating their underlying medical conditions so that certain safety precautions, specific exercises and training, and sometimes supportive equipment are also needed.
    Goal #1 is purposely broad. It lists examples of common and vaired seated areas a patient and their caregiver may have to circumnavigate in a home environment. I find it common that a person may safely manuever in one/some areas but not all, and so I may make measured comparisons to help explain what works/doesn’t work in one seated environment vs. another to justify the need for: equipment, additional caregiver training, more focused physical therapy exercise programs, and/or more focused short-term goals. For me, it’s not the equipment that should be the focus but the seated environment, available body mechanic strategies, and patient/caregiver deficits when transitioning in/out of certain areas in the home. Consideration of seat height, upper extremity strategies (i.e. pushing, pulling or a combination), and weight-shifting/positioning cues help describe and explain safe and risky transfers in/out of various seated environments at home and can inform all those involved of the need for other interventions.
    Last, I made my potty-post because I do not support linking the image of a commode with therapy services — what we do is so much more sophisticated than “toilet training” which is what is accomplished by parents and their children all over the world.
    I hope I have sufficiently answered your inquiry.
    Warm Regards,

  7. Tim says:

    Can you advance a home health to a MMT of greater than 4/5 if it pertains to reaching a functional goal?

    Thank you

  8. Diana says:

    I recently found this article while considering the terms “short term,” “long term” and “functional” goals. I find the comments to Nancy’s article missing her point. The choice of using a commode as a lead into a discussion of therapy goals may not have been the best, it does get our attention…..and that’s important. As a PT, I find we often focus on the details of our eval and treatment, but do not always relate the goals to the expected outcome.

  9. Diana, thank you for your comments. My frame of reference on this has to do with the “back end”, meaning working on denied claims in audits and investigations wherein functional deficit is not clearly defined (general “ADLs), or is not specific with respect to the patient, or having no context (walk community distances, or walk up and down stairs). Providing clarity about toileting with respect to function provides the context, as well as a sense of complicit understanding on the part of the reviewer. Who’s to argue that a purpose of physical therapy on “sit to stand” and “stand to sit” with respect to safely toileting is not skilled care?

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