Department of Health and Human Services 

OFFICE OF


INSPECTOR GENERAL 

PHYSICAL THERAPY


IN PHYSICIANS’ OFFICES


~ sWlc~$ ,*F, %, +’


2-- Jf JUNE GIBBS BROWN 

: 

:

‘s Inspector General 

‘b 

~ti, 4 MARCH 1994

4&~dJ{] 3 OEI-02-!WO0590 
OFFICE OF INSPEHOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Semites’ (HHS) 

programs as well as the health and welfare of beneficiaries setved by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management prob]ems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’S Office of Audit Sewices (OAS) provides all auditing semices for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIGS Office of Investigations (01) conducts criminal, civil, and administrative


investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of


unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions,


administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud


control units which investigate and prosecute fraud and patient abuse in the Medicaid program.


OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’S Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid. accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. 

This report was prepared in the New York Regional Office under the direction of Regional 

Inspector General Thomas F. Tully and Deputy Regional Inspector General Alan S. Meyer. 

Project Staff included: 

Ncw York Headquarters 

Rcncc C. Dunn, P.T. (Project Leader) Wayne A. Powell 

Lucille M. Cop, R.N. Barbara R. Tcdcsco 

William J. Counihan Linda M. MOSC(IC 

Nancy T. Hurrison 

To obtain a copy of this report contact the Ncw York Regional Office at (212) 264- 1’})S 
Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

PHYSICAL THERAPY 

IN PHYSICIANS’ OFFICES 
EXECUTIVE SUMMARY


PURPOSE 

To determine the nature and extent of physical therapy services provided to Medicare 

beneficiaries in physicians’ offices and to describe carrier monitoring of these sewices. 

BACKGROUND 

Physical therapy treatment consists of a planned program to relieve symptoms, 

improve function and prevent further disability for individuals disabled by chronic or 

acute disease or injury. Treatment may include various forms of heat or cold, 

electrical stimulation, therapeutic exercises, ambulation training and training in 

functional activities. 

Medicare has detailed coverage guidelines for physical therapy which apply to all 

outpatient settings, except physicians’ offices. While no specific coverage requirements 

exist regarding physical therapy in physicians’ offices, the services like all others, must 

be reasonable and necessary and not for palliation. As in any other area in Medicare, 

in the absence of HCFA national policy, local carriers establish their own policies. 

For outpatient settings other than physicians’ offices, Medicare requires the services 

must be restorative or for the purpose of designing and teaching a maintenance 

program for the patient to carry out at home. The services must also relate to an 

written treatment plan and be of a level of complexity that requires the judgement, 

knowledge and skills of a qualified physical therapist to, perform and/or supervise the 

services. The amount, frequency and duration of the physical therapy services must be 

reasonable. Lastly, the sewices must be considered reasonable and necessary and 

must not be palliative in nature. 

Medicare reimbursement for physical medicine services provided by physicians and 

independently practicing physical therapists increased by 40 percent from 1990 to 

1991. Allowed charges for these services in the HCFA common procedure code index 

(HCPCS) went from a combined total of $144 million in 1990 to $202 million in 1991. 

We selected a stratified random sample of 300 beneficiary cases who received physical 

therapy services ( 100 from independently practicing physical therapists’ offices and 200 

from physicians’ offices) in 1991 to compare sewices in physicians’ offices with those in 

another outpatient setting. We obtained the medical records of 166 of the physicians’ 

claims and 89 of the independently practicing physical therapists’. We conducted a 

medical review of the records, determined the percentage of cases which would not 

have met Medicare coverage guidelines had they been performed outside a physician’s 

office and those which were palliative and calculated the possible cost savings to 

Medicare. 

1 
The study team also interviewed, by telephone, 36 physicians, 20 physical therapists, 42


carriers and representatives of six professional associations to gather their perspectives


and concerns pertaining to physical therapy setices provided in physicians’ offices.


We also obtained and reviewed carrier documents regarding provider education,


policies and screens for physical therapy services.


FINDINGS


Alnwst Four Out of Five Cases Rei.mlxud as Physical l%erapy in Physicians’ Ofices Do 

Not Represent Tw Physical l’%eraW Services: $47 Million Was Inapproptitely Paid in 

1991 

The services are not restorative or complex nor do they have treatment plans with 

goals or objective evaluations. Most of the questionable services are palliative, giving 

only temporary relief and, therefore, are not covered under section 1862 (a)(l)(A) of 

the Social Security Act. The great majority of independently practicing physical 

therapy services meet all Medicare coverage guidelines; they routinely have plans of 

care, goals, objective evaluations and are restorative in nature. 

Cam-en Have Paid Little Attention to Physical Therapy in Phy.n”cians’0j5ces 

Two-thirds of the carriers have no policies concerning physical therapy in physicians’ 

offices. 

All Profw”onal Associatwm, Some Cam”ers,Physician and Phyn”cal l%erapy Respondents 

Encourage More StringentRequirement for Physical Therapy in Physicians’ Ofices 

Both professional physician specialty organizations and physical therapy associations


agree that physical therapy in physicians’ offices should be restorative and have goals


set forth in a plan of care. Over a third of the carrier respondents feel there are


problems with the frequency of physical therapy treatments in physicians’ offices, such


as overutilization and excessive sexvices.


RECOMMENDATIONS


We recommend that FICFA take appropriate steps to prevent inappropriate payments


for physical therapy in physicians’ offices. The HCFA can use the following


approaches to achieve this goal:


� Conduct focused medical review. 

� Provide physician education activities, 

�	 Apply its existing physical therapy coverage guidelines for other settings to 

physicians’ offices. 

ii 
We estimate that implementation of this recommendation would save $235 million 

over five years. 

COMMENTS


Comments on the draft report received from HCFA and the Assistant Secretary for 

Planning and Evaluation (ASPE) concur with the general thrust and significant details 

of our recommendations. Suggestions for changes in wording, clarifications of the text 

and technical changes have, for the most part been incorporated into the final report. 

The actual comments received are in Appendix B. 

The HCFA plans to share copies of the IG report with carriers and ask them to focus 

on issues identified in the report. Also, it has a work group considering alternative 

ways of providing appropriate physician education. The HCFA would like to analyze 

the results of these actions before changing coverage guideline policies. We support 

this approach and will, of course, be interested in the results of the analysis. 

Finally, while we appreciate ASPE’S desire to see a more explicit recommendation, it 

is our desire to allow the operating agency flexibility in addressing the concerns 

identified and developing corrective actions. 

... 

111 
TABLE OF CONTENTS


PAGE


EXECUTTVE SUMMARY


INTRODUCJ30N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7


�$47 Million inappropriately Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7


�Carriers Pay Little Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10


. More Stringent Requirements Encouraged . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14


APPENDIX


lk Sampling Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l 

B: Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l 
INTRODUCTION


PURPOSE 

To determine the nature and extent of physical therapy services provided to Medicare 

beneficiaries in physicians’ offices and to describe carrier monitoring of these semices. 

BACKGROUND 

Physical therapy treatment consists of a planned program to relieve symptoms, 

improve function and prevent further disability for individuals disabled by chronic or 

acute disease or injury. Any condition which requires physical rehabilitation, such as 

low back pain, bursitis, stroke, Parkinson’s disease, or arthritis, can benefit from 

physical therapy. 

A licensed physical therapist evaluates the patient, develops a treatment program and 

sets goals to meet each patient’s needs. This plan may include various types of 

therapeutic exercise, either manual or with the assistance of a machine, to decrease 

pain and improve strength, endurance, coordination, range of motion and mobility. 

Treatment may also include such modalities as hot or cold packs, whirlpool, diathermy, 

ultrasound, traction and electrical stimulation. These modalities are most often used 

in combination with exercise. Additional physical therapy treatments include 

ambulation training, assessment for orthotic or prosthetic devices, and functional 

training activities needed for daily living. 

An aging population and medical advances in the treatment of chronic disease have 

contributed to the need for physical therapy in recent years. The number of licensed 

physical therapists and the variety of settings in which they work have also increased. 

These settings may include acute care hospitals, outpatient clinics, home health 

agencies, independently practicing physical therapists’ offices or physicians’ office. 

All States have licensing laws and specific regulations pertaining to physical therapy 

practice. Physical therapists must pass certain educational and examination 

requirements to qualify for a license. Most States require that only a person licensed 

or authorized under their legislation shall practice physical therapy or use the title 

“physical therapist.” 

Medicare Coverage 

Medicare covers physical therapy in both inpatient and outpatient settings. Inpatient 

settings include institutions such as hospitals and nursing homes. Outpatient settings 

are independently practicing physical therapists offices’, outpatient clinics, home health 

agencies, rehabilitation agencies, and physicians’ offices. 

1

To bereimbursed by Medicare, allprovider settings, with theexception of physicians' 

offices, must be certified. AS part of the certification process, the State surveys each 

facility to assure that Medicare standards are met. During these surveys, the State 

representative reviews personnel records of staff giving care to be sure they are 

qualified. 

Covera~e in Physicians’ offices 

Medicare has detailed coverage guidelines for physical therapy which apply to all 

outpatient settings, except physicians’ offices. Medicare covers physical therapy in 

physicians’ offices as it does any other medical treatment, as incident to a physician’s


service. This means, according to the Medicare Carriers Manual (MCM) section 2050,


the semices must be: an integral part of a physician’s service; commonly furnished in


a physician’s office; rendered without charge or included in the physician’s bill;


performed under the direct (rather than general) personal supervision of the


physician; and performed by an employee of the physician. As any other physicians’


services, according to the Social Security Act, in the section on exclusions from


coverage, Section 1862 (a)(l)(A) states that,’’... no payment may be made under part


A or part B for any expenses incurred for items or services which,... are not


reasonable and necessary for the diagnosis and treatment of illness or injury or to


improve the functioning of a malformed body member.” This section goes on to say


that payment is prohibited for medical semices that are for prevention, palliation,


research, or experimentation. Palliation is generally defined as relieving or easing pain


temporarily. No specific MCM coverage requirements exist regarding physical therapy


in a physician’s office. As in any other area in Medicare, in the absence of HCFA


national policy, local carriers establish their own policies.


Coverage in outpatient settinus other than physicians’ offices


The MCM, section 2210, contains coverage requirements for independently practicing


physical therapists. The Medicare Intermediary Manual (HIM) contains similar


coverage requirements for other Part B outpatient providers of physical therapy,


including approved clinics, rehabilitation agencies, participating hospitals, skilled


nursing facilities, and home health agencies. The key elements in both manual


sections include:


.� The semices must be restorative with an expectation that the patient’s condition 

will improve significantly in a reasonable and generally predictable period of 

time based on the assessment by the physician and qualified physical therapist: 

or the services of a qualified therapist may be necessary to design and teach a 

maintenance program for the patient to carry out at home. 

.� The physical therapy services must relate to an written treatment plan 

established by the physician after consultation with the qualified physical 

therapist. “The plan must relate the type, amount. frequency, and duration of 

the physical therapy services ... and indicate the ciitignosis and anticipated 
goals.” The MCM states that the plan may be established by either the 

physician or the qualified physical therapist. 

The physical therapy service must be of a level of complexity and sophistication, 

or the condition of the patient must be such that requires the judgement, 

knowledge and skills of a qualified physical therapist to perform and/or 

supervise the services. 

The amount, frequency and duration of the physical therapy semices must be 

reasonable. 

To fulfill these requirements and demonstrate the patient’s restoration potential, the 

patient’s record must show objective measures of patient evaluations such as strength, 

balance, endurance, range of motion and activities of daily living. There must also be 

periodic review by the physician. 

The Medicare manual physical therapy guidelines for outpatient settings, other than 

physicians’ offices, discuss some of the more common physical therapy modalities and 

procedures utilized in the treatment of patients. They give examples of what would 

constitute Medicare covered physical therapy. For instance, simple heat treatments 

such as hot packs, cold packs, infra-red, and whirlpool, which do not ordinarily require 

the skills of a qualified physical therapist and when used alone are usually palliative 

(giving temporary relief), are not covered. However, such treatments may be given as 

a part of a more complex program and would be considered part of that physical 

therapy service. Also, in some cases where the patient has circulatory deficiency, areas 

of desensitization, open wounds or other complications, the skills and judgement of a 

qualified therapist may be necessary and, therefore, covered. Other more complex 

modalities such as ultrasound, shortwave, and microwave diathermy treatments must 

always be performed by or under the supervision of a qualified physical therapist, and 

would then constitute physical therapy. 

To be covered by Medicare, range of motion tests must be performed by qualified 

therapists. Range of motion exercises require the skills of a qualified therapist only 

when they are a part of active treatment for a specific disease; the degree of motion 

lost and the degree restored must be documented. Generally, range of motion 

exercises which are not related to a specific loss of function, but intended for the 

maintenance of function, do not require the skills of a qualified therapist. However, 

the therapist could design a program of maintenance exercises for the patient and 

Pamily to carry out, and Medicare would cover it. 

Therapeutic exercises which must be performed by or under the supervision of the 

qualified therapist, due to the type of exercise or the condition of the patient, are also 

covered. Gait evaluation and training with a patient who has impaired function would 

require the skills of a qualified physical therapist, but would be considered physical 

therapy only if the patient can be reasonably expected to improve his or her ability to 

walk. Repetitive exercises to improve gait or m:lint:lin strength and endurance, or to 

3

assist a feeble patient in walking, do not require the skills of a qualified physical 

therapist. An example would be a patient who has generalized weakness and needs 

assistance and encouragement to walk and to increase his/her endurance. This semice 

could be carried out by a non-physical therapist such as a nurse or nurse’s aide, but 

would not be considered covered physical therapy. 

Medicare Reimbursement 

Medicare reimbursement varies for different physical therapy providers. Medicare 

pays both inpatient and outpatient institutional providers on a reasonable cost basis. 

Physicians and independently practicing physical therapists in their offices are paid on 

the basis of a Medicare fee schedule. The independently practicing physical therapists 

are, however, subject to a yearly $750 reimbursement limitation per patient. 

Medicare reimbursement for physical medicine services provided by physicians and 

independently practicing physical therapists increased by 40 percent from 1990 to 

1991. Allowed charges for these services in the HCFA common procedure code index 

(HCPCS) went from a combined total of $144 million in 1990 to $202 million in 1991. 

Medicare reimbursement for the three most commonly reimbursed physical therapy 

HCPCS codes for physicians and independently practicing physical therapists shows a 

273 percent increase over the five-year period from $24.8 million in 1986 to $92.1 

million in 1991. In one year, from 1990 to 1991, allowed charges for just these three 

codes increased 26 percent from $73.3 million to $92.1 million. The three codes are 

97010, physical treatment of one area of the body with hot or cold packs; 97110, initial 

physical therapy treatment of therapeutic exercise in one area of the body for 30 

minutes and; 97128 ultrasound treatments. 

Prior Study 

A 1982 HCFA Region II validation study raised certain issues. The fact that these 

issues remain is one factor that prompted the present inspection. The prior study 

noted that there were no HCFA directives addressing physical therapy services 

furnished by physicians in their offices and thus no requirement that the care be 

restorative. However, there were HCFA instructions governing the same therapy for 

other outpatient providers, including independently practicing physical therapists. The 

study also reported the absence of HCFA guidelines addressing the reimbursement of 

non-restorative, palliative treatment billed as physical therapy in either setting. The 

medical record review identified 57 percent of the total study semices in physicians’s 

offices as palliative care. The study recommended that HCFA establish uniform 

guidelines for the coverage and reimbursement of restorative physical therapy services. 

It also recommended that non-restorative services be reimbursed as a part of medical 

semices, but not separately as physical therapy. No action was taken. 
METHODOLOGY 

First, we selected a stratified random sample of 300 beneficiary cases. Each case 

represents all physical therapy semices received by a sample beneficiary from a single 

provider in 1991. The sample consists of the HCFA common procedure coding 

system (HCPCS) codes 97010 to 97799. One stratum included beneficiaries who 

received physical therapy services in independently practicing physical therapists’ 

offices and the other stratum included beneficiaries who received services in 

physicians’ offices. The independently practicing physical therapists’ offices were 

selected as a representative of other outpatient settings with which to compare 

services in physicians’ offices. One hundred of the beneficiaries treated by 

independently practicing physical therapists were chosen from the first stratum and 

200 by physicians from the second stratum (see appendix A.) This sample of 300 

beneficiary cases was handled by 42 Medicare carriers, whom we contacted to obtain 

the names of the providers in each of these claims. 

Next, we asked the providers to send us copies of all of the sample patients’ physical 

therapy medical records for the period of 1990 to the present. We received 255 (85 

percent) of the 300 records requested; 166 records from physicians and 89 from 

independently practicing physical therapists. The study team created a review form 

for the medical records based on Medicare coverage guidelines for physical therapy 

provided in all outpatient settings other than physicians’ offices (where there are no 

guidelines). A HCFA physical therapist reviewed the form and found it an acceptable 

way to determine whether the treatment would constitute covered physical therapy. A 

physical therapist and registered nurse from the study team reviewed the medical 

records to ascertain whether there was a written treatment plan with diagnosis and 

anticipated goals; whether the care was restorative with the expectation that the 

patient would improve significantly in a predictable period of time; whether a 

maintenance program was designed and taught; whether objective testing was done; 

whether the services were palliative; and whether the amount, frequency and duration 

of the services was reasonable. We next compared the medical records of physicians 

with those of independently practicing physical therapists to identify differences or 

similarities regarding semices provided, the type of person providing them, and levels 

of documentation. Based on the results of this medical review, we determined the 

percentage of semices which would have met Medicare coverage guidelines had they 

been performed outside a physician’s office and calculated the possible cost savings to 

Medicare if these coverage requirements for physical therapy were applicable to that 

in physicians’ offices. 

We also selected a stratified random subsample of 60 of the 300 providers, 40 

physicians and 20 independently practicing physical therapists to interview by 

telephone. We were able to contact 36 of these physicians and all 20 of the 

independently practicing physical therapists. We asked both groups how ph~sical 

therapy in physicians’ offices compares to that in independently practicing physical 

therapists’ offices, and about the qualifications of the person in their office providing 

the service and compared their responses. 

5

We reviewed carrier documents related to physical therapy, which 40 of the 42 carriers 

submitted, regarding their provider education, po]icies and screens. We identified 

billing restrictions and screens or other controls, both pre-and post-payment. Also, we 

interviewed, by telephone, staff experienced in physical therapy coverage and 

reimbursement from the 42 carriers in our sample to gather their perspectives and 

concerns pertaining to physical therapy services provided in physicians’ offices. 

Lastly, we interviewed representatives of two physical therapy associations and four 

other medical specialty organizations to gain their views on physical therapy in 

physicians’ offices. 

6

-——.-

FINDINGS


ALMOST FOUR OUT OF FIVE CASES (78 PERCENT) REIMBURSED AS


PHYSICAL THERAPY IN PHYSICIANS’ OFFICES DO NOT REPRESENT TRUE


PHYSICAL THERAPY SERVICES: $47 MILLION WAS INAPPROPRIATELY


PAID IN 1991


Most of the questionable services are palliative, therejore not covered under section 1862 

(a)(l)(A) of the Social Security Act. They are not restorative or complq nor h they 

have treatment plain with goai%or objective evaluations. 

The physical therapy sexvices in physicians’ offices are generally some form of 

palliative treatment giving only temporary relief, such as hot packs, whirlpool, 

ultrasound, diathermy and/or massage, often given by unlicensed people without any 

exercises or functional activities. Almost three-quarters of the physician medical 

records do not show the physical therapy services to be of a level of complexity to 

require the judgement, knowledge and skills of a qualified physical therapist. Only 13 

percent of the cases involve exercises. When physicians were asked about the kinds of 

semices they provide, over one-third of the physician respondents report that they only 

provide some type of heat. This group includes 13 of the 15 podiatrists interviewed. 

only 38 percent of physicians interviewed report that they ever provide exercises. 

The 1991 HCFA data show that the most frequently reimbursed physical therapy 

procedures in physicians’ offices are hot or cold packs and ultrasound. Table A below 

shows the fiscal year 1991 frequency and allowed amounts for the top eight physical 

medicine codes in physicians’ offices only. These are ranked in terms of dollars 

allowed. 

TABLE A 

: HCPCS ~DESCRIPTION I FREQUENCY ~ ALLOWED \ 

~ CODES ~ ! AMOUNT ~ 

~ 97128 ~Ultrasound ! 1,145,900 ~$~o, 182,800 ~ 

j 97010 ~ Hot or cold packs ‘ 1,111,100 ‘ $19,214,900 ‘ 

[ 97110 ! Therapeutic exercises : 811,000 , $16,174,100 ~ 

! 97014 : Electrical stimulation (unattended) 464,300 $s,401,400 

~97022 ~Whirlpool 558,700 $8,279,400 ~ 

i 97530 I Kinetic activities ~3~,300 $6,805,400 . .. 

! 97124 ~Massage 375.500 $6,384,300 ~ , 

: 9711s Electrical stimulation (manual) ~~&joo” $5,719,300” --==- ---= .—. ——.—.=.— =..

7 
Most physical therapy care in physicians’ offices is not restorative nor does it establish 

a maintenance program. Almost four out of five cases (130 out of 166) would not 

meet the primary Medicare guideline for physical therapy in other settings that 

sefices be restorative or for the establishment of a maintenance program. Of the 36 

cases in physicians’ offices meeting the guidelines 26 have restorative care and in ten a 

maintenance program was established. 

The medical record review reveals that the physical therapy patients get in physicians’ 

offices is usually provided too sporadically and infrequently to achieve any goals in a 

predictable time and is therefore not restorative. The following are examples of nonrestorative care found in the medical records: 

C)ne patient treated by a specialist in internal medicine who employs a physical


therapist has osteoarthritis and pain in the knee, neck and back. She visits her


physician once every month or two. She receives physical therapy once or twice


a week, off and on, with a treatment of hot packs and massage and sometimes


ultrasound. The physical therapist’s notes generally say patient tolerated


treatment well and that sometimes she feels better after treatment, and


sometimes not. This care appears to be palliative with temporary relief at best;


no real functional outcome can reasonably be expected.


In another example, a specialist in internal medicine occasionally administers


ultrasound to his patient with chronic arthritis of the right shoulder during a


routine visit. The record shows no objective evaluations or plan of care or any


expected functional outcome from the ultrasound treatment.


over two-thirds (114) of the physician’s medical records had no written treatment plan


for physical therapy and over three-quarters (128) of the records have no physical


therapy goals spelled out. Further, over two-thirds (113) of the physicians’ medical


records have no objective evaluations with which to measure the patient’s progress.


Of those that do have a treatment plan with goals, the goals include increasing


function, strength and range of motion, decreasing pain, and improving ambulation.


of those with objective evaluations, the majority evaluated range of motion and/or


pain.


Among difierent physician groups, podiixoists are least likely to provide care tha[ ir tndy 

physkal them~. 

only two of the 47 cases from podiatrists show restorative care. Almost two-thirds of 

the non-restorative podiatry care was palliative. The remaining one-third was related 

to surgery such as whirlpool to soften the skin and nails prior to debridement or a post 

operative cold pack to prevent swelling. In most cases these treatments were provided 

once every month or six weeks when the patient routinely visited the podiatrist. 

Seventy-eight percent of podiatrists had no treatment plan; 82 percent had no goals. 

and S0 percent had no objective evaluations (see tuble B below.) 
TABLE B


FEW SPECIALTIES WOULD MEET THE PHYSICAL THERAPY 

REQUIREMENTS FOR OTHER OUTPATIENT SE’ITINGS 

Orthopedic Physical 

Surgery Medicine 

& Rehab 

N=28 N=8 

(10:%) 

(2:%) 

(7?%) (8/%) 

(6~%) (7:%) 

General 

Medical Podiatry 

Practice + 

N=66 N=47 

(1?%) (2:L) 

(6i) ] (1;%) 

m 

I 

(9i) (4i) 

Others* Totals 

N=17 N=166 

(3:%) (3:;) 

38 

(3:%) 

(3:%) 

(1:%) 

28 general 

Has 

Treatment 

Plan F
 Has goals

Has objective 

evaluations 

Care Either 

Restorative 

or 

~ Establishing 

I Maintenance 

~ L
Program

The numbers within each specialty are not mutually exclusive. 

+ General Medical Practice includes 29 family practitioners, 

practitioners, and 9 internists. 

* Others include 4 general surgeons, 2 cardiovascular specialists, 2 clinics, 2 

unknowns, 2 osteopaths, an anesthesiologist, a dermatologist, a plastic surgeon, 

a radiologist, and a pediatrician. 

Physical therapy services in the offices of orthopedic surgeons and physical medicine 

and rehabilitation specialists are more likely to be restorative or for the establishment 

of a maintenance program than to be palliative. The medical records of more than 

two-thirds (19 of 28) of the orthopedic surgeons’ and three-quarters (6 of 8) of the 

physical medicine and rehabilitation specialists’ show restorative care or the 

establishment of a maintenance program (see table B above.) This compares to only 

four percent of the podiatrists, nine percent of those in general medical practice 

(including internists) and 18 percent of the other specialties. 

The physical therapy services are also more likely to be performed by a licensed 

physical therapist or occupatiomd therapist in the offices of orthopedic surgeons and 

9

physical medicine and rehabilitation specialists than in other physicians’ offices. All of 

the 2S orthopedic surgeons had licensed professionals providing the physical therapy 

services, 25 had physical therapists and three occupational therapists. Of the eight 

physiatrists, three had physical therapists, two physical therapy assistants and the 

remaining performed the physical therapy service themselves. None of the podiatrists, 

only eight percent (5 of 66) of those in general medical practice and 18 percent (3 of 

17) of the other specialties had licensed physical therapists or occupational therapists 

performing the sefices. 

Ntie out of ten casa in independently practicing physical therapk’ ofices meet all 

Medicare coverage guidelines; thq routinely have plhs of car% goak and are restorative 

in nature. 

The great majority (88 percent) of the independently practicing physical therapists’


medical records document medically necessary restorative care or the establishment of


a maintenance program. The services are always provided by a licensed physical


therapist or, in one case, a licensed physical therapy assistant. The remaining care


appears to be palliative.


Almost all independently practicing physical therapists’ medical records have a written


treatment plan (92 percent) with goals established (81 percent). Over three-quarters


(79 percent) of the patients with goals met these goals in a predictable period of time.


Almost all independently practicing physical therapists’ records had objective


evaluations to measure the patient’s progress. These evaluations include range of


motion, muscle strength, pain, gait, posture, sensation, functional activities, and


activities of daily living.


Most of their physical therapy treatments are complex. In over three-quarters of the


independently practicing physical therapists’ records, the patient was either evaluated


or performed exercises or functional activities, all of which are complex activities. All


independently practicing physical therapist respondents reported that they provide a


whole range of services, usually including exercises or functional training in conjunction


with modalities such as heat or electrical stimulation.


CARRIERS HAVE PAID LITTLE ATTENTION TO PHYSICAL THERAPY IN


PHYSICIANS’ OFFICES


Four-jiftti of the carriers have no polici~ concerning the r~torative nature of physica[ 

therapy in physicians’ ojj’ices. 

Although each carrier is expected to establish local policy where no national HCFA 

policy exists, twenty-four of the 42 carriers have no policy for physical therapy in 

physicians’ offices. (krier documentation and intemiew responses by carriers and 

physicians reveal that most carriers require little information other than what is on the 

initial claim form. One, however, requires that a plan of treatment for services by 

physicians be attached to claims for physical therapy. Another requires a physician 

note on the claim thilt there is a treatment plan available for physical therapy services. 

1() 
In contrast, all carriers require some sort of documentation by independently 

practicing physical therapists that a treatment plan is available. Some require the 

treatment plan itself and others require a notation on the claim saying that the 

treatment plan is available. 

Tencarriers have policies such asnotreimbursing physical therapy on the same day as 

an office visit without a separate diagnosis or only reimbursing specific HCPCS codes. 

These policies do not relate to the restorative nature of physical therapy services. 

Eight carrim ti their instructions indicate physical thera~ must be restorative; howeve~ 

no enfoxement k apparent. 

Eight carriers have policies relating to the restorative nature of physical therapy 

services. Six of them have sent newsletters or bulletins to physicians mentioning the 

need for physical therapy services to be restorative. One restricts this policy to 

physiatrists. one of these eight carriers has a screen dealing with the restorative 

nature of the physical therapy services. A review of the medical records from claims 

reimbursed by these carriers, however, shows that they are not enforcing these 

restrictive policies. They approved the same percentage of non-restorative care as 

other carriers in our sample. 

PROFESSIONAL ASSOCIATIONS, AS WELL AS SOME CARRIERS, 

PHYSICIANS AND PHYSICAL THERAPISTS, ENCOURAGE MORE 

STRINGENT REQUIREMENTS FOR PHYSICAL THERAPY IN PHYSICIANS’ 

OFFICES 

Professional associations contactai agree that physical therapy in physicians’ ofices 

should be restorative. 

Physician specialty organizations such as the American Academy of Physical Medicine


and Rehabilitation, the American Osteopathic Association, the American Academy of


Orthopedic Surgeons and the American Podiatric Medical Association and


professional physical therapy associations, the American Physical Therapy Association


and an organization of Independent Private Practitioners all agree that physical


therapy in physicians’ offices should be restorative and should have goals set forth in a


plan of care. The representative from the osteopathic society says, “It should not go


on indefinitely. It should not be done indiscriminately.” The response from the


Academy of Physical Medicine and Rehabilitation was that, “PT should also maintain


function and prevent complications, PT may be instructional for the development of


home maintenance therapy programs. Modifications to maintenance programs are


frequently necessary, ... guidelines are needed to prevent abuse.” The American


Academy of Orthopedic Surgeons expresses similar feelings, “Physical therapy in a


physician’s office should follow the same guidelines and requirements as therapy


performed in a free standing physical therapy office.”

Some carrkrs, physicians and physical therapists have concerns about physical therapy 

sewices provided in physicians’ ofices. 

Over a third of the carrier respondents feel there are probiems with the frequency of


physical therapy treatments in physicians’ offices, such as overutilization and excessive


semices. One carrier, concerned about possible overutilization of physical therapy


modalities by physicians, requested an opinion from its State Society of Physical


Medicine and Rehabilitation. Some of the features included in its guidelines,


developed as a result of the Society’s opinion, follow the Medicare guidelines for


independently practicing physical therapists. The State society opinion also states


“There is limited justification for treating multiple areas with modalities... The use of


modalities on a sporadic basis concurrent with routine office visits is not justified”.


Other carriers agree physicians are billing for too many physical therapy services. One


respondent suggests, “HCFA should have better guidelines. We should rebundle


therapy, heat treatment is a part of several modalities. A lot of services are being


given, I feel, that are unnecessa~.” One carrier noted that they had 25 doctors on


their Provider Audit List (PAL) who billed for too many physical therapy semices, too


many times with no documented medical necessity.


Physical therapy in podiatrists’ offices is of particular concern to several carriers. One


carrier reported that prior to 1992 it denied physical therapy for podiatrists since the


semices were considered to be part of a visit code. However, evaluation and


management codes do not contain physical therapy, so the carrier now pays for both.


Some carriers express the need to monitor podiatry semices more closely. A number


agree that whirlpool which is used to soften nails or tissues prior to debridement is not


really physical therapy. One podiatrist supports this by saying, “We have found it


(physical therapy) beneficial for patients. We use it frequently following a procedure.


but not usually on its own when the patient is not in the office for another reason.” In


contrast, another podiatrist states, “It should be done every other day or every third


day for several weeks and evaluated, not just every few months when the patient


comes in. Then it’s a foot washing.”


Physical therapists also voice concerns about the frequency and care in physicians’


offices. One therapist says, “We have had complaints by patients who have got


physical therapy in a physician’s office. They said they got too many treatments that


were not necessary.”


The use of licensed prof~sionah to provide physical thera~ servictx is encouraged by 

some. 

The American Academy of Orthopedic Surgeons in an advisory statement dated 

December 19S9 said, “Quality of care considerations dictate that the patient receives 

physical therapy semices which meet the highest professional standards. Only properly 

trained and certified physical therapists should be involved in the patient’s treatment,” 

The American Physical Therapy Association in its Qualifications for Persons Providing 
Physical Therapy Services says, “Protection of the public interest requires that physical 

therapy be provided only by persons who have successfully completed specialized 

education in that field and whose practice complies with well-defined regulations.” 

The association also suggests in its response that providers of physical therapy services 

in a physician’s office should be required to put their State professional license 

number on the billing forms. 

Some carriers have concerns about who is giving the care. One carrier respondent 

voices the concern of others when she says, “Lesser qualified people are used by 

physicians to give physical therapy, they are not using physical therapists.” Another 

adds, “We have no way of knowing who is giving physical therapy in a physician’s 

office... the physician should explain who did it and why on the claim itself.” Another 

respondent says, “I would like HCFA to state that a physician cannot hire a person to 

do physical therapy unless that person is licensed.” 

Some physicians also had concerns about who provides the care. An orthopedist 

voices the concerns of others when he says, “If doctors are billing for physical therapy 

by other than a therapist, it should be stopped. Having a nurse put hot packs on is 

not physical therapy.” All physical therapists agree that physical therapy should be 

performed by a physical therapist. One therapist says, “Physical therapy should be 

given by a licensed physical therapist, technicians have no idea why we do what we do, 

or the physiological ideas behind therapy.” 

13

RECOMMENDATIONS


We recommend that HCFA take appropriate steps to prevent inappropriate payments


for physical therapy in physicians’ offices. The HCFA can use the following


approaches to achieve this goal:


. Conduct focused medical review, 

� Provide physician education activities, 

.� Apply its existing physical therapy coverage guidelines for other settings to 

physicians’ offices. 

We estimate that implementation of this recommendation would save $235 million 

over five years. This figure was calculated by multiplying $47 million per year by five 

years. 

COMMENTS


Comments on the draft report received from HCFA and the Assistant Secretary for


Planning and Evaluation (ASPE) concur with the general thrust and significant details


of our recommendations. Suggestions for changes in wording, clarifications of the text


and technical changes have, for the most part been incorporated into the final report.


The actual comments received are in Appendix B.


The HCFA plans an alternative course of action to the IG suggestion to conduct


focused medical review. It plans to share copies of the IG report with carriers and ask


them to focus on issues identified in the report. In response to the suggestion that


HCFA provide physician education activities, it has a work group considering


alternative ways of providing appropriate physician education. The HCFA would like


to analyze the results of these actions before changing coverage guideline policies. We


support this approach and will, of course, be interested in the results of the analysis.


The HCFA also raised several technical comments. Noting that our sample consisted


of HCFA common procedure coding system (HCPCS) physical medicine codes, HCFA


was concerned that services other than physical therapy may have been included in


our sample. We confirmed that the service was actually physical therapy through


review of actual services in the medical record. The HCF.4 also noted increases in


reimbursement and asked for further information. We focused on coverage in this


study and do not have sufficient information to determine why there has been a 40


percent increase in reimbursement for physical therapy codes.


14

The ASPE raised several technical points regarding the basis of overpayments, the 

projection of our results, and the intent of our recommendations. The basis for our 

determination that overpayments were made is the nature of the services, rather than 

the individual providing them. Our method of sampling allows us to project our 

results (see appendix A for further details). Finally, while we appreciate ASPE’S 

desire to see a more explicit recommendation, it is our desire to allow the operating 

agency flexibility in addressing the concerns identified and developing corrective 

actions. 

15

APPENDIX A


SAMPLE SELECIION AND PROJJXIIONS 

We extracted all Physical Therapy services (FICPCS 97010-97799) from a 1% Part B 

Common Working File (CWF) sample of 1991. There were 123,950 sexvices for 8,562 

beneficiaries which totalled approximately $1,800,000. The file was sorted by 

beneficiary and date of service to facilitate categorizing beneficiaries by the specialty 

of the provider. 

The two provider categories were independent physical therapists (IPT) and all types 

of physicians. We used the first occurrence of each beneficiary’s semice to determine 

the provider category. Therefore, if the beneficiary had services from more than one 

provider, only one provider was sampled. There were 2,078 beneficiaries in the IPT 

group and 6,484 in the physician group. Simple random sampling was used to select 

semices within each category of provider. The sample consists of 100 IPT services and 

200 physician semices. 

Beneficiary medical records were requested for the sample 300 cases, however, 45 

beneficiary records were not sent. From the sample of 100 beneficiaries who received 

semices from IPTs, 89 were sent and from the 200 beneficiaries requested from 

physicians offices, 166 were sent. After reviewing a beneficiary’s record, it was 

determined whether or not the care given was restorative or for the establishment of a 

maintenance program. If it did not fit either of these categories, we determined them 

to be “non-covered.” If the decision was that the care was non-covered, all physical 

therapy services for the beneficiary/provider combination in 1991 were assumed to be 

non-covered and the estimated savings was based on the amount for the non-covered 

semices. If the beneficiary was treated by more than one provider, only data from the 

sampled beneficiary/provider combination was used to estimate the savings. Separate 

estimates were calculated for physicians and IPTs. Standard statistical formulas were 

used to estimate the total savings and to compute a confidence interval around the 

estimate. The table below shows the distribution of beneficiaries and allowed charges 

from the one-percent Part B Common Working File for 1991. 

1% Part B Common Working File in 1991 

Beneficiaries Allowed Beneficiaries Allowed 

in Universe amount in in Sample Amount 

universe In Sample 

IPT 2,078 $733,488 — 100 $37,S76 

1

The table below shows the covered and non-covered status of allowed charges based 

on the result of the medical record review for physicians and IPTs. 

Physicians 

Result of Number of Allowed Number of Allowed 

Review Beneficiaries Charges in Beneficiaries Charges in 

in Sample Sample in Sample Sample 

Covered 36 $5,733 78 $30,496 

Non-covered 130 $14,512 11 $5,192 

No Records 34 $4,760 11 $2,188 

Received 

Total 200 $25,005 100 $37,876 

Nearly 20 percent of the medical records from physicians’ offices were not received 

and approximately 6 percent of the medical records from IPTs were not received and 

therefore not reviewed. Of the received records, the percent of dollars for noncovered cases in physicians’ offices is about 72 percent ($14,512/$20,245). Projected to 

the Medicare population the $14,512 is estimated to be approximately $47 million. 

The 95 percent confidence internal for the estimated $47 million is $27.7 million to 

$66.4 million. This estimate was computed by multiplying the unweighed amount by 

the inverse of the probability of selection (6,484/200) and then by 100 to weight from 

the 1 percent file to the population. By comparison, the estimated amount for noncovered care provided by IPTs was only about 15 percent (5,192/35,688) of the total of 

covered and non-covered amounts. The unweighed amount of non-covered care in 

IPTs’ offices was projected in the same manner to obtain the estimate of $10.8 million. 

A-’2

APPENDIX B 

COMMENTS 

B-1 
. .. 

..ACJ. ~! 

DEPARTMENT OFHEALTH a HU,MANSERWCES 

Hoakn Cm


Fhncma Admirvatratlan


Memorandum---

Ja&giq#q 

Office of Inspector General (OIG) Drdt Rqafi ‘PtyiuI Therapy in Phydc;*’ 

Ofices’ (OE142-!XMKJ590) 

June Gibbs Brown 

I.napectorGeneral 

We have rcvicwcd the above-referenced draft repon which exaxain= the nature ~d 

extent of phyaid therapy semkes provided to Medicare beneficiaries in physic!!n# 

offices, and desai%es ~“er monitoring for kse aati~ 

Based on tic biing~ OIG recommended that the Health Cue Financing 

Administration take appropriate steps to prewnt inappropfiata payments for 

physical thenpy in physicians’ offb. These steps cuuld include focused rncdical 

rcvkw, physician education activitiq and applying &sting phyafral therapy 

cmeraga guidelines for ether settings co physicians’ c&- OKI rhnatea that 

implczm.matian of tbia resommendaticn wculd mrt S235 miIiion over 5 ymn We 

cone~r with the overau r~o~eadaticn. We agree with the first Wa optiIxI,A but 

disagree with the third. Our detailed comments are attached for your 

consideradcn. 

Thank you fcr the opportunity to retiew and ccrnment on this draft repafi Pkxse 

advise us if you wish to discuss cm: position cm the repon’s recommendations at 

your earliest cimvenferxe. 

Attachmczt 
. 

We re~~end that HCFA tie appropriatestep topreventinapFr@a& 

paymeats fcrphyskl thempy hI phyaidans’ of&ss. EICFA canuse the fcbwing 

Bppraachm to achieve Ma god: 

Conduct focuxd medical review. 

We ecmcur uhti this opdq but prop= an alternadve cnurac of den hn 

focmed rnedicd review speciffcal.ly. We would like tQ diatiuts espies of OIG’s 

repart to the carriers with a caver note asking them to review it and f-c on the 

issues idcztified in the rep- We will ask the carricra to publixb pertinent 

infomatbn presmtedin0K3’sreport ccmcerningsppropriam bflling of physical 

therapy scmices in their quarttrly bulletins to providcra. For example, -Aem 

ccruid list commau pa]tiative semicrx that may be pefiormed in offic~ but that we 

not caverec? regardless of where the semhs xc delivered. 

QQQn2 

Provide ph@cian education a.cdvities 

~ere iscurreatIya workgrcupwithin HCFA”S Bureuuof policy Dcvc!oprmnt 

ccmpriseci of carrier physicians and phpical ‘&ra@m that is k.xdng on physicai 

tlmr~p~ in general. TMJ edxing work group b considering alternative ways of 

prawdmg apprcpiatc physician educmion cu drninistcrkg physfcal the:spy in 

phy3ician cfficu. 

Apply &stiig physic.d thcmpy cawc:sge g-uic?efies fcr ather scttitigt to phprism” 

Officu. 
Page 2

RCF A Rc:s on5e

We would lie to implement and anal: thf reslts of the fi tWo option before

changmg e.nge guidelie policies for physci efce a.rv

010 c.n Jy poinu aut, phy medcie aees funrcd in ph Qif are cO'red under the lIincluent to" preon of Mec. Under thc

incident to prevon. a ph)'ic mAY employ J.u%i persel to a.t 

renderig semcet. The ph)'ci include. the charges for such au:ry pcn.n.el servcu in his aw bil.

IJthough there are no detae. CQeragc guideline. for physca therpy in ph)1!lcia

offce:! the Social Security Act requires the aeMecs to be reuonable and n

for the di::gnoas and tr tme:t of ile. or jwy or to improv thc functicning of

3. malormed body member. AI poited cut in the rcpcn, payment is prom.oltbd for medial sec for prevention, palticn resuch or enution. Curen eatabli their cw poHde. to int.rprtt and Impcaa thes requircmen on ph

serv We beU "'e that impl!.mentig the fit tW Qption wi1 prcdc idh

to the locl amers as well 31 to physcian I, en wb2t are deemed

rea30nllbte and nc S!ary to re,tcre functiniDg under the extig incident to provion.

Tl.hnit:1 Comments

CIG' s sample cOIlsi:sU!d of the HCF A c.on procedure ! l)em (HCICS) codes 97010 to 97799. We would lie to point out that th coes ar for 

medicinc, which may have b n us.d to report servces other than phytc. thcnpY. Therefore, OIG' . cmpbasil OIl whether thC3 servcu represnt 8tre physc1 tber pY may be tated. The aelcdon of this t of Ctes.may af the validity of the fidig that aIaou feur out of fie ca re.buncd as physc: thcrnpy in pb)"icians' off do not represent tre ph)"al tberapy servces would be inter tc:d OD OIG' s ! k On ths point.

The report Jta tbat there W' a S4a million mcreue from 1990 to 1991 in MediC:e reimbunemcnt for physcal medicie servc. It wold be ulcful to 'cow whether th inC' C3used by camu from phytci abuli the sy, cpp ed to phytc:u the pis the legisted inc:e from SSOO to $750 i:l the: C3p on c:brges fer pb. t: and ooJp!. ona. ther3py 'eM or SCe other C3u

This inlon: rion would help u, evac:1te whether the. recencation ..ld ,o!"e t.,e problem of inc:re3. es iI thb &Iel. cr if 3bu$e by phyrans is a $mal pi of A much luger problem. .

On page A- 2. the p r3gI1ph fol1C"g !.e bblc: i... lic CC' JhC\Id rc:

nc: 9 pcr nt conEde:1c. icterv! fcr tbc e,tmAt.d S4i trilcn 527.7 milon to S66.4 lDilio:: (nt:c:r than $6. 4 milo.).
,.....

DEPARTMENT Of HEALTH 

&. 

HUMAN SERVICES Offce ot the Secretary

l(i

PDIG

DIG-AS

DIGAIG-MP

OGIIG

EX SEC

Dj,TE SENT

Washington, D.C. 20201

AUG 2 3 

:: n c: C1 rn rr

(; 

maG

.

.t rn -- IT ::z- ;: UJ -c

1- 

o c:

TO:

FROM:

Bryan B. Mitchell

Principal Deputy Inspector General

Assistant Secretary for

Planning and Evaluation

SUBJECT: OIG Draft Report: "Physical Therapy in

Physicians' Offices" 

CONCUCE WITH COMMS E/-tJ2- fit) -tJOSC;O

This report examines the nature and extent of physical therapy

services provided to Medicare beneficiaries in physicians' offices , and also describes carrier monitoring of these 

In brief, ASPE recommends that services. OIG: 1. ) clarify which cause of inappropriate payments is examined in -

appropriateness of generalizing the study' the data , 2. ) discuss the

recommendations more explicit s results; 3. ) make the

changes. , and 4. ) make minor editorial

1. Clarifv which cause of inaDDroDriate paYments is examined in the data We believe 

at is report identifies two distinct reasons why many PT services provided in physicians' offices

would not be reimbursed if provided in any other outpatient setting. These causes (which are not mutually exclusive) are:

) that the nature of e ser ices was inappropriate (i. was palliative , non-complex , or not related to a trea plan with goals or objective evaluations). ent

discussed on pages 6-9. This cause is

that individual providincr e services was not appropriately qualified. This cause is discussed in quali- tative te s on pages 11-12.

Upon first reading this report , we were uncertain if it was addressing one or both issues. Upon closer inspection, we recognized that claims had been inspected 

the nature of the services was appropriateto dete ine only if

We thus realized , not e providers. at the quantitative fi dings refer only to 

first of e t o potential causes of i appropriate payments.

Given that clai:ns fOn1s do not indicate who provided "

, we understand that FT" servic- is study was not able to deten1i

However

extent of i

, to avoid confusion

appropriate pa ents d e to qualified providers.

, we recO end at orG:
r.-

, ,

Page 2 - Bryan B. Mi tchell

1. ) distinguish between the two potential causes of inappropriate payments early in the report , and explain that due to data limitations the quantitative aspects of the report

address only the first.

state that , because of the possibility of unqualified

persons providing services of an appropriate nature

incidence of inappropriate payments may be higher than the , the

findings indicate. 

2. Discuss the appropriateness of qeneralizinq the studv' s resul ts The conclusions of this study are based on a sample

which is relatively small and which is also subject to nonresponse bias. Due to these limitations , we recommend that the report explicitly discuss whether the results are simply suggestive or if they are considered to be generalizable to the entire

Medicare population.

3. Make the recommendations more exPlicit

recommendations be expanded as follows: We suggest that the

"Conduct focused medical review" - This recommendation should include the answers to the following of what? For issues: Review what purpose? Would this require collecting any data beyond what is collected at present?

"Provide 'Chvsician education activities" - Some specific examples of education activities would be helpful 

Also here. , given that on page 10 the report suggests that education without enforcement is not effective, this recommendation should mention that enforcement measures may also be

necessary if education efforts are to have their desired effect.

Also , the report should explicitly state that the figure of $235

million of savings was calculated by multiplying $47 million per year by five years.

4 . Make minor editorial chanqes

- In the fou paragraph, second sentence ere should not be a comma after the word " goals"

IL - In the third full paragr-aph , last sentence

, 

should read " ay" many"
.' t ..

Page 3 - Bryan B. Hi tchell

In the second paragraph, 

limit of the confidence interval should not be $6. four sentence, the Upper

4 million.

/: 

David T. Ell. 

Prepared by: c. Prentice/rg 690-7994