Understanding Lifestyle Management Services for Treating Pain: Documentation and Case Study Examples

Learning Outcomes

• After this course, participants will be able to identify a patient's relevant past medical history, occupational profile, and occupational performance deficits in order to document and evaluate and develop long-term goals for a patient with chronic pain.
• After this course, participants will be able to recognize effective documentation practices including use of medically necessary language, measurable goal setting, and use of functional outcomes.
• After this course, participants will be able to review a pain management case study and list effective occupational therapy interventions and strategies to use to address identified performance deficits.

Thank you for being here with me today. I am excited to speak with you about lifestyle management services for treating, documenting, and billing effectively for pain.

Lifestyle Management Strategies for Chronic Pain

I want first to review overall lifestyle management strategies for chronic pain. Figure 1 shows an overview of the typical OT interventions used in a lifestyle redesign approach depending on what is identified in the evaluation as a patient's performance deficits. We tailor the process accordingly.

Figure 1. Overview of specific OT interventions used in lifestyle design.

LRD Chronic Pain Management Program

• Lifestyle Redesign® for Chronic Pain Management: A Retrospective Clinical Efficacy Study
  • 45 patients
  • 9 OT sessions for 18 weeks
  • Dx: lumbago, myalgia/fibromyalgia, CRPS

(Simon, A. U., & Collins, C. E., 2017) 

I also want to touch upon lifestyle redesign and evidence with this approach. We conducted a research study that looked at these specific lifestyle management approaches to determine the effectiveness of a lifestyle-based occupational therapy approach for patients with chronic pain. We included 45 patients who attended an average of nine occupational therapy sessions over 18 weeks using a lifestyle management approach. There were a variety of different chronic pain diagnoses included in the study. 

Lifestyle Redesign® 

• Lifestyle Redesign® is the process of acquiring health-promoting habits and routines in daily life.

(Jackson et al., 1998)

Lifestyle redesign is acquiring health-promoting habits and routines in daily life.

Outcomes for Pain and Mental Health LRD Programs

• COPM
• RAND-SF 36
• Brief Pain Inventory
• Pain Self-Efficacy Scale
• Fibromyalgia Impact Questionnaire
• Beck Depression Inventory
• Perceived Stress Scale
• PHQ-2 or PHQ-9

Some of the pain and mental health outcome measures administered to our participants include the COPM, RAND SF-36 Quality of Life, Brief Pain Inventory, and the Pain Self-Efficacy Scale. We also incorporated other outcome measures depending on different mental health comorbidities or other pain conditions. 

Study Results

• RAND-SF 36 QOL
  • Role limitations due to physical health↑  20.16pts
  • Role limitations due to emotional problems  ↑  25.27 pts
  • Social Functioning  ↑  15.23 pts
• Pain Self-Efficacy
  • Overall self-efficacy  ↑ 4.46 pts
• COPM
  • Improved performance ↑ 2.02 pts
  • Improved satisfaction ↑ 2.78 pts
• Brief Pain Inventory
  • Small improvements in pain severity and pain interference scores

The study revealed that participants improved in role limitations caused by physical health, emotional problems, and social functioning using the RAND-SF 36 Quality of Life outcome measure. They also demonstrated improvements in overall self-efficacy, which is their belief in their confidence and ability to manage their pain symptoms. On the COPM, they met the minimal clinical significance or a two-point improvement in performance and satisfaction. They also reported improvements in pain severity and pain interference scores on the Brief Pain Inventory. It was great to see a lot of excellent outcomes and improvements using this lifestyle redesign approach.

• LRD “has a significant effect on the QOL, self-efficacy, and functional abilities of people living with chronic pain.”
• “Lifestyle modifications can effectively manage chronic conditions and improve overall QOL.”

(Simon, A. U., & Collins, C. E., 2017) 

In summary, the lifestyle redesign program significantly affects the quality of life, self-efficacy, and functional abilities of people living with chronic pain. 

Documenting Lifestyle Management Interventions for Pain: Evaluation and Treatment Notes

There is evidence to support that these interventions work with that background information. Still, as a profession, we need to make sure that we can document and bill effectively to justify these services.

Evaluation

Next, we will look at the evaluation and treatment process and how to document the lifestyle management interventions for treating chronic pain. The evaluation process outlined in Figure 2 shows the areas of occupation and the most severely affected areas.

Figure 2. Areas of occupation that are affected by chronic pain.

We need to understand how certain areas of occupation are impacted by chronic pain so that in our documentation, we highlight some of these known factors. Looking at the OT Practice Framework and areas of occupation, research shows that chronic pain affects areas of psychosocial functioning, sleep and fatigue management, physical function, cognitive performance, mood, personality, and social relationships. Not only do we want to be aware of this during our evaluation, but we also need to know the purpose of this documentation.

Barriers to Chronic Pain Self-Management

1. Lack of social support
2. Limited resources (financial, transportation)
3. Depression and stress
4. Ineffectiveness of self-management strategies
5. Time constraints and other life priorities
6. Avoiding activity because of fear of pain exacerbation
7. Lack of tailoring strategies to meet personal needs
8. Inability to maintain use of strategies
9. Physical limitations 

(Bair et al., 2003)

Here are some of the barriers to chronic pain self-management. If a patient lacks social support or has limited resources, this can impact their prognosis and ability to implement some lifestyle recommendations. And, if there is a presence of mental health comorbidity, this can change how we treat the patient. A client may not have great awareness of triggers or self-management strategies to help them manage their pain. Other things like time constraints might impact their ability to attend and participate in OT sessions. Fear-avoidance behaviors, lack of tailoring strategies to meet their needs, and an inability to maintain the recommended strategies are limiting. Lastly, any physical limitations are barriers.

It is essential to document these barriers because these are important if an insurance company reviews your documentation for why the patient is not making rapid progress.

Evaluation: Occupational Profile & Medical History

• Medical History
  • Story of pain over time
  • Comorbidities and how they influence pain (especially mental health)
  • Symptoms (other than pain)
  • Known triggers
  • Possible triggers
    • Photophobia
    • Phonophobia
    • Osmophobia
    • Aura
    • Posture
    • Dietary
    • Menstrual cycle
    • Temperature
    • Stress
    • Skipping a meal
    • Computer use
    • Air quality
    • Too much/too little sleep
    • Too much/too little physical activity 
  • Exacerbating activities
  • Alleviating activities
  • Location, duration, the intensity of pain
  • Frequency & pattern of pain; recent flares
  • Medications: efficacy, side-effects
  • Other therapies (past or current) for pain

I think most of us are familiar with the OT evaluation process, but I want to highlight some of the pain-specific considerations. In that gathering of the occupational profile and medical history, we want to touch on each of these points listed here. It is essential to understand the client's pain over time, how it has changed, and how it has progressed or gotten better. We also need to understand what comorbidities are present. It always is nice to have patients recognize what other symptoms they are experiencing along with pain.

Do they have an awareness of what their triggers or exacerbating factors are? Do they have an understanding of things that might help alleviate their pain? The answers to these questions can give you insight into the patient's level of readiness for change, whether they are aware of those things or whether there is a complete lack of awareness of those patterns.

Some known triggers are listed. If a patient is unaware of those, you may want to ask about their pain, including location, duration, intensity, frequency, and medications. It is also essential to know if the client participates in any other treatments or therapies during your OT process. ​

We need to look at the client's daily habits and routines and understand what a good versus a bad pain day is and how that might impact their functional abilities.

• Occupational Profile
  • Background
  • Social supports & resources
  • Interests
  • Barriers (poor self-awareness, catastrophizing)
  • Supports (existing self-mgmt. skills)
  • Pt. goals
• Prior level of performance
  • Sometimes pre-injury
  • Often includes pre-existing chronic pain levels

In the occupational profile, we want to note their social supports, barriers, leisure interests, and their goals for occupational therapy. We also want a baseline of the patient's prior level of performance before the onset of pain or injury.

Evaluation: Client Factors Affecting Occupational Performance

• Values, Beliefs, Spirituality
  • Cultural, societal, religious beliefs that positively or negatively affect the pain experience and may influence the treatment of pain
• Mental functions
  • Higher-level cognitive functions, executive functions, attention, focus, concentration, memory, difficulty establishing habits & routines, energy & drive, sleep
• Psychosocial/coping
  • Stress, anxiety, depression, poor-self-efficacy
• Body structures & functions
  • Structures related to the nervous system, movement, etc.
  • Functions: posture, fall risk, balance, joint mobility/stability, muscle power/tone/endurance
• Sensory functions
  • Pain: baseline, with activity, patterns throughout the day, etc.
  • Note that “baseline” might be hard for pts to identify

The next part of the evaluation looks at the client factors affecting occupational performance. First, what are their values, beliefs, and spirituality? I always like to check if they follow any religious or spiritual practices that help them cope with pain, which could be a tremendous support. Or, are their pain symptoms interfering with their ability to engage in any spiritual or religious practices? We also want to know their beliefs and thoughts about pain. This is where you might get a sense of a person's risk for catastrophic thinking. If they have any of those thought patterns or feel like there is absolutely nothing they can do to help manage their pain, this might be a barrier that you might note in your documentation.

As far as mental functions go, living with chronic pain can impact things like cognitive performance, memory, attention, and sustaining attention because the pain is so distracting. It is so important to check in on how mental functions are impacted by pain.

We also want to look deeper into their psychosocial and coping mechanisms for pain, stress, and anxiety management. We can also point out the relationship between pain and stress as a two-way relationship in the evaluation process. Do they notice an impact of stress on their pain levels? It might not be something that they are aware of yet, but it is something that you may delve into during treatment.

We also want to evaluate specific body structures and functions and how pain may be impacting their posture, functional mobility, strength, and things like that. Is their pain causing sedentary behaviors, further leading to muscle weakness and increased pain? And then lastly, we want to assess sensory functions. What are their pain levels, and how did their pain levels change?

And, are there other changes in sensory functions like sensitivity to light, sound, temperature, or things like that?

Evaluation: Occupational Performance Deficits

• ADLs/Self-Care
  • Bathing, toileting, dressing, feeding, mobility, hygiene, sexual activity
• IADLs
  • Caregiving, communication, driving, health mgmt. & maintenance, home mgmt., meal prep, spiritual practice, shopping, medication mgmt. 
• Rest/sleep
  • Falling asleep, staying asleep, falling back asleep after waking, pain during sleep or upon waking
• Health Management
  • Eating and exercise routines, medication mgmt., self-regulation, symptom and condition mgmt., communication mgmt.
• Education; Paid or unpaid work
  • Job performance & maintenance, employment interests & pursuits, volunteer exploration
• Leisure/play; Social participation
  • Play/avocation participation & exploration, family/peer/friendship participation

(American Occupational Therapy Association, 2020)

Once we have an idea of the client factors affecting occupational performance, we need to understand their occupational performance deficits. We need to look at the different categories from the Occupational Therapy Practice Framework (OTPF) to understand how their pain impacts their ability to engage in any of the activities listed here.

As I go through these questions with patients, it is always nice to get a baseline measurement. For example, if they have a hard time preparing a meal because of their pain, I want to get some baseline measurement of what level of assistance is needed or how often they have to ask for help? I also want to know their tolerance and how long they can stand in the kitchen before the pain gets triggered? This baseline measurement information will be helpful when I write up my long-term goals. So, it is not just about understanding if pain impacts activity, but it is also getting measurable baseline components so that you can write effective long-term goals.

Evaluation (Pain-Specific Tips)

• Also, document how emotional state impacts pain and function:
  • Depression, anxiety, stress
  • Social isolation
• Watch for the polarity of pain:
  • good days vs. bad days
  • variation of pain and dependence of activity/function on pain level that day/moment
• Reflect how occupation impacts pain, not just how pain impact's function

As you go through the evaluation, you want to document how a person's emotional state impacts pain and function. As I mentioned before, there is a two-way relationship between stress, anxiety, depression, and pain. First, does the patient have a mental health comorbidity, and second, do they know if their stress is unmanaged? We also need to recognize any risk for social isolation and document that. You may want to screen for suicidal ideations if that is appropriate.

We also want to highlight the difference between good days and bad days, or days when pain is better managed versus during a flare-up. How does their functional performance vary based on good versus bad days? We want to highlight how occupational engagement impacts pain and how pain impacts their function.

Evaluation: Clinical Decision-Making

• When choosing treatment plan options, relate each intervention to an ID’d performance deficit.

With all of that information, think about the performance deficits and client factors influencing performance to develop this treatment plan (Figure 3).

Figure 3. Example of a treatment plan.

All of these options listed could be addressed in an OT treatment plan. However, be mindful of the occupational performance deficits you identified earlier in your assessment. Let's say the pain was impacting their ability to sleep effectively. You want to make sure that the treatment plan addresses sleep. You do not want a hole to be in the treatment plan process. You want to relate each intervention to an identified performance deficit.

Outcome Measures

• Pain
  • Visual Analog Scale
  • Brief Pain Inventory (BPI)
  • Pain Catastrophizing Scale
  • Pain Self-Efficacy Questionnaire
  • Pain Anxiety Symptom Scale 
• Mental Health
  • Beck Depression Inventory
  • Patient Health Questionnaire (PHQ-9 or 2)
  • Generalized Anxiety Disorder (GAD-7)
  • Perceived Stress Scale
• Overall Quality of Life
  • Canadian Occupational Performance Measure (COPM)
  • 36 Item Short Form Survey (SF-36)

In addition to that semi-structured interview and the occupational profile, it is nice to have a qualitative assessment to give you some baseline information to include in a treatment plan or re-evaluation to report measurable changes in their scores. These are some of the outcome measures that we use at our clinic.

Pain Assessment

• Common diagnosis-specific assessments
  • Fibromyalgia Impact Questionnaire-Revised (FIQR)
  • Migraine Disability Assessment Test (MIDAS)
  • Migraine Specific Quality of Life (MSQL)
  • Headache Inventory Test (HIT-6)
  • Headache Management Self-Efficacy Scale (HMSE)
  • Oswestry Low Back Pain Disability Questionnaire
  • And MANY more…

There are several other ones specifically for evaluating pain. If there is a mental health comorbidity, you can use any of these measures. We tend to use the COPM and the RAND SF-36. And then, if other specific diagnoses or other things are coming up during the evaluation, we move to more diagnosis-specific assessments.

Documentation, Billing & Reimbursement

How do we document the evaluation and bill and get reimbursed for that appropriately? As a review, this is just a summary of why documentation is so necessary.

Purpose of Documentation

• Communicate information about the client's occupational history, experiences, interests, values, and needs;
• Articulate the rationale for the provision of occupational therapy services and the relationship of those services to client outcomes;
• Provide a clear chronological record of client status, the nature of occupational therapy services provided, client response to occupational therapy intervention, and client outcomes
• Provide an accurate justification for skilled occupational therapy service necessity and reimbursement.

(Kearney & Laverdure, 2018)

Documentation is an opportunity to communicate information about a person's lived experience, occupational history, interests, values, supports, barriers, and rationale for why OT services are needed. Whatever we document needs to justify the need for OT skilled intervention and related outcomes. We also want to make sure that the documentation provides a clear record of changes in the client's status and allows someone to continue with the treatment plan if need be. Lastly, we want to justify why our skilled intervention is necessary and why it should be reimbursed.

• Document OT’s unique contribution to chronic pain management
• Focus on occupation, activities, and participation
• Include analysis and modifications of environmental and contextual factors
• Use of a holistic, biopsychosocial approach to address common comorbidities
• Use of occupational therapy specific outcome measures (i.e., COPM)

(Lagueux, Dépelteau, & Masse, 2018)

Occupational therapy is the only discipline that looks at occupational performance, activity, and participation in relation to pain. Thus, we need to ensure that our documentation highlights and reflects that. We do a lot of training and education, but it is vital that our documentation explicitly ties that back to occupational engagement.

Another unique aspect of OT is the evaluation of environmental factors and context, task analysis, and activity modifications. We need to highlight these treatments in our documentation. We use a biopsychosocial approach, treat the patient holistically, and do not just treat the pain. I think that we know as OTs that if we were just to treat the pain, our progress with the patients would only go so far. We have also to address the psychosocial factors that are likely contributing to their experience of the pain. Do not hesitate to include documentation about those factors and how you are handling that in your treatment.

It is crucial to incorporate OT-specific outcome measures. Other disciplines may use some of the same ones that we use in our practice, but the COPM, for example, is unique to our profession, so it is nice to incorporate that into your documentation as well.

Payer Guidelines for Documentation

• Relates back to the plan of care and diagnosis
• Demonstrates skilled OT
• Patient response to treatment
• Document progress, set goals'
• Choose CPT that matches what you did in the sessions

To get reimbursed for services, you need to ensure that your documentation relates to the plan of care and the diagnosis. I recommend that you explicitly tie it back to the diagnosis that was included on the referral form by the physician in your writeup. This could be as simple as saying something like, "To improve the management of fibromyalgia..." It is making that explicit link.

Again, we want to demonstrate skilled OT intervention as stated previously. How do we highlight our unique contribution to treating chronic pain? One, we need to report on the patient's response to treatment. So if we are providing education or training in a particular area, and the patient has demonstrated that skill, we need to include their response to that treatment. Did it trigger pain? Were they able to demonstrate the skill without any cues?

It is essential to document progress like changes in pain levels, activity tolerance, independence in certain activities, etc. In our sessions, we set short-term goals to achieve by the next session.

CPT Codes and Billing

• 97165/6/7 OT Evaluation (LOW/MOD/HI complexity)
• 97168 Re-Evaluation 
• 97150 Therapeutic Group
• 97110 Therapeutic Exercise
• 97129 Cognitive Function 
• 97530 Functional/Therapeutic Activity 
• 97535 ADLs/Self-Care 
• 97537 Community/Work Reintegration 
• 97112 Neuromuscular re-education
• 97140 Manual Therapy

To get reimbursed for the services, we need to choose the correct CPT code that matches our session. For example, if we work on self-care and home management, we need to use that specific CPT code. Above are some of the standard CPT codes used for lifestyle management interventions for chronic pain. This is by no means all of the CPT codes that we have access to, but these are the more common ones. More often than not, I use the 97535 code, but I also use community/work reintegration and functional/therapeutic activity. If there is a cognitive impact from the pain, then use the cognitive function CPT code. 

CPT® Occupational Therapy Evaluation “Occupational Profile”

• LOW 97165
  • “An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem”
• MOD 97166
  • “An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.”
• HI 97167
  • “An occupational profile and medical and therapy history, which includes a review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current function performance.”

(Brennan, McGuire & Metzler, 2016)

And then this is just an overview, again, generally going through that OT evaluation process. I think most of us are familiar at this point with the different complexity codes that are associated with the evaluation procedure. For each section of the evaluation, we need to code it to match what we are documenting depending on the severity of the patient's pain story and how it impacts their function.

For the occupational profile and understanding their medical history, it might be low complexity if it is a more recent injury or they have not been experiencing chronic pain for prolonged periods. A moderate rating would be if the pain is the primary concern, but they do not have too many other health comorbidities. High will be if there are many other factors contributing to their experience of chronic pain.

CPT® Occupational Therapy Evaluation “Occupational Performance”

• LOW 97165
  • “An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions. “
• MOD 97166
  • “An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive or psychosocial skills) that result in activity limitations and/or participation restrictions.”
• HI 97167
  • “An assessment(s) that identifies  5 or more performance deficits (i.e., relating to physical, cognitive or psychosocial skills) that result in activity limitations and/or participation restrictions.” 

(Brennan, McGuire & Metzler, 2016)

Looking at occupational performance, this is the same thing. We need to make sure that we are coding low, moderate, or high appropriately by thinking about the number of identified performance deficits.

CPT® Occupational Therapy Evaluation “Clinical Reasoning”

• LOW 97165
  • “Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.”​
• MOD 97166

  • Clinical decision-making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.

• HI 97167

  • Clinical decision-making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

(Brennan, McGuire & Metzler, 2016)

For the treatment plan, you identify what areas you are going to address and the treatment options based on their performance deficits. If there are only a few deficits, it may be low complexity; however, if there are a lot of different performance deficits, it may be more moderate or high.

For the final billing code of the evaluation, you use the lowest level of complexity identified in those three categories. For example, if the occupational profile was low complexity, but the occupational performance and clinical reasoning areas were moderate complexity, it would be billed overall as a low complexity evaluation. 

Long-term Goal Setting

• Decrease pain (frequency, intensity) or trigger/exacerbation of pain
• Improve self-management skills
• Client factor modification
• Functional deficit reduction
• Use outcomes as evidence, but not as the goal itself

You then use the information from the evaluation to write effective long-term goals to guide your treatment. Overall, the goals for this population are to decrease their pain experience, whether that is reducing the frequency or intensity of the pain or the frequency of their flare-ups, and improve their self-management skills like recognizing and preventing exposure to triggers, implementing pain coping strategies, or taking their medications more effectively. It may also look at things like client factors or environmental modifications to reduce functional deficits, reduce their level of dependence on other people, or improve their activity tolerance.

It is always nice to have those outcome measures as evidence of improvement, but it is not the goal itself. We do not want to write a goal that the patient will improve their COPM overall performance score by two points, as that does not measure functional progress. It does demonstrate progress if they improve that COPM score, but we want our goals to be function and occupation-based.

Plan of Care Long-term Goals

• Area of focus: Body part, type of cognition, psychosocial factor, etc.
• Impairment: What is the deficit? Pain, strength, ROM, balance, endurance, stressors, skill deficits…
• Impairment Goal: Measurable expectation of improvement – VAS, COPM, ROM, Number… 
• Functional Activity: Dynamic and complex – cooking, dressing, driving, occupation…
• Target Performance: Distance, amount of time, product…
• Rationale: Why is this important? Self-care, caregiver burden, functional independence, safety, community reintegration…
• Target timeframe: When will this be done? 2 weeks, 4 visits, 10 visits…

When writing long-term goals, we want to make sure that we are clear about our focus. What functional activity will we use to improve patient outcomes, and what is their target performance? This is where the baseline performance level comes into play. In our long-term goal setting, we highlight the target we are working toward. I will go through a few examples in just a second.

What's the rationale for it? Why is it essential that we address this long-term goal? This is where we might explicitly connect the deficit and the goal. For example, we could target sleep routines to improve nervous system regulation to reduce migraine triggers. We also want to make sure that long-term goals include a target timeframe to inform you of when to re-evaluate. Insurance companies also want to see that target timeframe.

Goal Setting Template:

• In time frame, Pt will improve functional performance deficit by improving client factors/reducing limitations, as evidenced by measurable target performance (baseline measurement), to address management of diagnosis.

This is a template that I put together that can be used to write long-term goals to make sure you are touching all of those components. 

Goals: Examples

• In 12 sessions, Pt will improve participation in cleaning home management IADLs by improving endurance and energy mgmt., as evidenced by increasing independence from moderate assistance to minimal assistance to address management of fibromyalgia.
• In 8 sessions, Pt will improve sleep/rest IADLs by improving sleep wind-down routines and positioning supports, as evidenced by engaging in a relaxing sleep wind-down routine 5/7 nights, to address management of low back pain (baseline: engaging in sleep wind-down routine 1/7 nights).
• In 10 sessions, Pt will improve participation in work by reducing exacerbation of stress, as evidenced by implementing x1 relaxation technique per day in the workplace, to address management of chronic migraines (baseline: not using stress management coping strategies).

Using this template, I provided a few examples. In the first one, there is a target timeframe. The way we will measure progress is evidenced by their increased independence in home management tasks from moderate assistance to minimal assistance. This focuses on helping them manage their fibromyalgia symptoms better.

Another one looks at sleep routines. The patient will improve their sleep routines by improving their wind-down habits and incorporating positioning supports within eight sessions. We ask the patient to engage in a relaxing sleep wind-down routine five out of seven nights to manage their back pain better.

The final one looked at the client's baseline where they were only engaging in relaxing activities one night a week. By adding this, it makes it very easy to measure progress. When you go to re-evaluate a patient, you can ask them, "How many nights are you engaging in a sleep wind-down routine?" I cannot emphasize that baseline measurement component enough. 

Treatment Note: Demonstrating Skilled Intervention and Medical Necessity

I included some tools and resources that you guys can use. These are some of the verbs that I think help to demonstrate skilled interventions that we use as OTs. 

• Verbs:
  • Added
  • Assessed
  • Cued (verbal, proprioceptive, manual, etc.)
  • Customized
  • Demonstrated
  • Developed
  • Educated
  • Evaluated
  • Facilitated
  • Implemented
  • Instructed
  • Maximize/increased
  • Minimized/reduced
  • Modified
  • Monitored
  • Prevented
  • Progressed
  • Provided
  • Recommend
  • Trained
  • Collaborated
  • Engaged

I have included verbs like "modified" and "trained." "We provided education," or "We monitored the patient during an activity." These are some examples. This is by no means a hundred percent comprehensive list, but this is something that you can refer back to strengthen your documentation as you are writing a treatment note.

• Examples:
  • Independent carry-over of
  • Patient presents with decreased participation due to
  • Patient was assessed/measured/analyzed for…
  • Patient was provided with verbal/tactile/proprioceptive cues to…
  • Patient was instructed and received training for…
  • Activity tolerance/efficiency and/or task effectiveness (use length of time)
  • Therapist engaged client in….. problem-solving activity
  • Therapist facilitated client exploration/analysis of…daily living skill
  • Therapist trained/educated/instructed…..compensatory activity to increase independence
  • Therapist assessed client’s ability to…
  • Therapist demonstrated… technique/strategy for…
  • Therapist modified/added…
  • Therapist provided client with resources for...

These are also some of the taglines that you can use to report on what you have done in a session. For example, "The patient was assessed to determine activity tolerance of writing," "Trained in how to use a piece of adaptive equipment to make writing less painful, and then was "Reassessed while using that piece of adaptive equipment." "The patient reported improved tolerance." These are examples of taglines that you can add to your daily note documentation. 

Now, I am going to go over a few case examples.

Pulling It All Together: Case Example 1

Overview

• Patient was evaluated and has a diagnosis of carpal tunnel syndrome, which is interfering with his ability to perform childcare tasks and computer work tasks. Pt denies any mental health comorbidities.
• Low Complexity Evaluation (97165)

This client was referred with a diagnosis of carpal tunnel syndrome. The pain was interfering with this patient's ability to perform daily childcare responsibilities and computer work tasks. At the time of the evaluation and after gathering their occupational profile, the patient did not report any other comorbidities they were managing. Thus, it was billed as a low complexity evaluation. There were only two main performance deficit areas, so the performance and clinical reasoning areas were also low complexity. All three of those categories ended up being low complexity, and therefore it was billed as a low complexity evaluation. 

Treatment Note: Skilled Intervention

• OT trained patient in proper body mechanic techniques to improve neutral positioning of upper extremities during childcare IADLs to reduce risk for nerve impingement and exacerbation of carpal tunnel syndrome pain. Pt return demonstrated proper body mechanic technique by lifting a 15 lb exercise ball, 3x. Pt stated, “doing it this way does not trigger pain.”
• OT educated patient re: the risks of overactivity and prolonged repetitive activity participation on exacerbating carpal tunnel pain and trained patient in new pacing strategies to increase frequency of breaks during repetitive typing activities at work. OT recommended ergonomic equipment modifications that promote neutral hand and wrist positioning. Patient trialed use of x1 new ergonomic keyboard and reported reduced pain from an average of 8/10 during typing to 5/10. 

These examples show how the treatment session was documented to demonstrate skilled intervention and highlight the CPT codes used. I trained the patient in proper body mechanics techniques and how to achieve neutral positioning during childcare tasks to reduce the risk of nerve impingement and the trigger of carpal tunnel syndrome pain. I am tying it back to that specific pain diagnosis, making that explicit connection.

After doing the training, I reported on the patient's response. "Patient returned demonstrated the proper body mechanic techniques." The way he did this was by lifting a 15-pound exercise ball three times and stating, "This does not trigger my pain." In addition to reporting on the patient's response and progress objectively, you can also include some of those subjective responses. Using the lifestyle management approach, patients are going to report a lot of subjective progress, like, "I am sleeping better," "I am managing my stress better," or "I'm able to tolerate this activity better." This all addressed the childcare component.

For work, I educated the patient about the risks of overactivity and repetitive strain and how that can exacerbate carpal tunnel syndrome symptoms. I trained him in new pacing strategies and different approaches to work tasks. In addition to that pacing training, I also recommended some specific ergonomic equipment and environmental modifications to implement into his computer workstation to improve the neutral position of his hand and wrist. He trialed the use of an ergonomic keyboard. While he was typing, he reported a reduction in his pain levels using the new adaptive equipment.

In that daily note component, you can see I am explicitly tying it back to the diagnosis and using skilled intervention language of education and training. I am also using the unique OT role of environmental modifications. I am also highlighting occupational engagement of childcare and work tasks.

I also report that patient's progress and outcomes of less pain with lifting and typing. 

Treatment Session: Long-Term Goals

• In 12 sessions, Pt will improve participation in childcare IADLs by improving posture and body mechanics, as evidenced by increasing tolerance for holding his son from less than 1 minute to 3 minutes at a time, to address management of carpal tunnel syndrome.
• In 12 sessions, Pt will improve participation in work by improving ergonomic environment and activity pacing, as evidenced by increasing tolerance for typing from 2 minutes to 10 minutes, to address management of carpal tunnel syndrome. 

The long-term goals focused on childcare and work participation. So using that same template, in 12 sessions, the patient will improve participation in childcare tasks by improving posture and body mechanics as evidenced by increasing tolerance for holding his son for less than a minute to three minutes. That is the target performance. We are providing training to help him improve his management of carpal tunnel syndrome. For the work goal, the patient would improve participation and tolerance for typing by improving his ergonomic environment and using a pacing approach.

These both address the management of carpal tunnel syndrome.

Treatment Session: CPT Codes Billed

• Total treatment time: 60 minutes
  • 97535 ADLs/Self-Care – 35 minutes, 2 units
  • 97537 Community/Work Reintegration – 25 minutes, 2 units

We billed a combination of 97535 and 97537 codes. I spent about 35 minutes with the client for childcare body mechanics training and then 25 minutes on the pacing and ergonomic components for engaging in work tasks. This is what I put on my billing sheet. The documentation I provided matches those two codes and what we did during the session. And then lastly, at the end of the treatment session, we set some short-term goals for him to work on based on the training and education provided during the session.

Short-term Goal Setting

• By next visit, patient will implement proper body mechanic techniques during childcare IADLs by practicing holding his son for 2 minutes, 1x/day.
• By next visit, patient will improve pacing during typing work tasks by increasing the frequency of breaks from 1x every 120 minutes to 1x every 45 minutes. 

One of the short-term goals was that he was going to use proper body mechanic techniques during his childcare activities by practicing holding his son for two minutes at a time, once a day. This task is very measurable, and it is something that when you check in with the patient, he is going to be able to say if he completed it or not. The other goal was that by the next visit, the patient would improve his pacing during his work tasks by increasing his frequency of breaks from one time every two hours to one time every 45 minutes to prevent repetitive strain from prolonged use. We can tie this into the baseline measurement of only taking a break every 2 hours. We want to increase that frequency of breaks and see how that then impacts his pain.

Another potential short-term goal may have been, "Patient will incorporate the use of an ergonomic keyboard at his workstation." Did he acquire an ergonomic keyboard, implement using it into his workday, and did this affect his pain? These are examples of follow-up questions when you see that patient for their next session. "How did those short-term goals go?" "How did that impact your pain levels and symptoms?" You can see if they met those goals and problem-solve any barriers that might have come up.

This is what a treatment session would look like including the evaluation, follow-up treatment session, and short-term goal setting. Hopefully, this ties all of those pieces together and gives you some good examples of that.

Another case study will look at a patient's overall experience in OT, not just one treatment session or evaluation.

Pulling It All Together: Case Example 2 (Mark)

Overview

• 63 y/o male, high school teacher
• Dx: CRPS (Complex regional pain syndrome); Type 1 in bilateral hands
• Injury 5 years prior to OT treatment caused by repetitive motions at work
• Symptoms: aching & shooting pain
• Triggers: fine motor movements, stress
• Alleviating factors: deep pressure
• Other treatments: physical therapy
• Seen for initial evaluation and 19 treatment sessions

Mark is a 63-year-old high school teacher and was referred to OT to treat CRPS type one in bilateral hands. By the time he got to OT, he had been injured for five years, caused by repetitive motions at work. He was experiencing aching and shooting pain in both of his hands, and he did have some awareness about the triggers. Fine motor repetitive movements caused pain during heightened stress, particularly at work or in his relationship. He identified that deep pressure was helpful for him, and when he was not doing work-related tasks or on vacation, his pain levels were reduced. There is some awareness that stress triggered his pain and that enjoyable activities relieved it. He worked with both occupational and physical therapy and a pain management physician. He also used medications to help manage his pain symptoms.

Functional Impact

• Functional impact:
• Interfered with work productivity and functional performance (i.e., handling papers, handwriting, typing)
• Difficulty pacing himself
• Poor management of stress
• Reduced driving tolerance

He was seen for his initial evaluation and 19 follow-up treatment sessions. These sessions originally started once a week, typically how we try to start. We begin at a higher frequency, and then as they build up their skillset and become more independent in managing their pain, we may spread that out to once every two weeks or once every three weeks for the maintenance phase.

At the time of the evaluation, Mark reported problems with work and productivity. He had difficulty handling papers, handwriting, and typing, which were daily teaching activities. He was also having a hard time pacing himself through his workday and could not manage his stress effectively. Driving was very challenging for him because of the demand of holding the steering wheel and his long commute. This was a triggering activity for him.

Lifestyle Management Areas

• What are treatment topics/goal areas that you would want to address with this patient?
  • Compensatory strategies/AE training
    • Handling papers
    • Handwriting/Typing
    • Driving
  • Stress and anxiety management
    • Relaxation techniques
    • Avoidance of unnecessary stress
  • Exercise routines​
    • Incorporating deep pressure (weight-lifting)
  • Cognitive-behavioral therapy
    • Strategies to reduce negative self-talk

These are overall lifestyle management areas. We looked at compensatory strategies and adaptive equipment training to help him complete work tasks effectively. We also made adaptations to his driving routine and commute schedule. We worked on stress and anxiety management since that relationship was apparent for him. We gave him coping strategies to help him manage his stress and relaxation techniques like meditation, mindfulness, and breathing exercises to promote parasympathetic nervous system activation. This helped him reduce his pain, so he implemented relaxation techniques into his daily routine.

For his commute, he took the train to work, which eliminated the pain flare up at the beginning of his day. He engaged in relaxation techniques on the train or read a book for leisure. This schedule modification helped him to manage his pain more effectively.

He started an exercise routine because of his report that deep pressure alleviated pain. We also looked at pacing during exercise. 

Lastly, looking at stress and anxiety, we incorporated some cognitive behavioral therapy strategies to reduce the negative self-talk that he was having. 

Long-term Goal Setting

• Practice writing a goal to address his functional deficits at work
• In 10 sessions, patient will improve performance at work by improving tolerance for computer activities, as evidenced by implementing use of adaptive equipment during typing and mousing to decrease CRPS pain.

Outcome Measures

And the evidence or the outcome measures that demonstrate progress are all listed in Figure 4.

Figure 4. Chart of outcome measures for Mark. Click here to enlarge the image.

We used the RAND SF Quality of Life. You can see his baseline, discharge scores, and changes. Higher scores indicate improvements in any one of these categories. On the COPM, his overall performance and satisfaction scores improved by at least two points, which is lovely to see. For the Brief Pain Inventory, his average and worst/least pain levels improved, and the pain interference was reduced. So, the impact of his pain on his ability to do his daily activities improved after OT treatment. Finally, his Pain Self-Efficacy Questionnaire score improved from the initial evaluation to discharge. The higher scores demonstrate a higher self-efficacy.

Hopefully, these examples help tie in all of that information for each of you. 

Questions and Answers