The right forearm skin graft is doing well as is the donor site from his right thigh. There is no signs of infection and it is time to start physical and occupational therapy to improve range of motion, strength and activity.
Mr. Lane lives 45 minutes from the nearest town with physical therapy services and there is no occupational therapy available locally.
Mr. Lane reported the following about his pain at his physical therapy appointment:
- Pain is constant with intermittent numbness and tingling RUE
- Pain Aggravating Factors: activity, self-care activities, dressing, and RUE
- Pain Relieving Factors: Rest, medication.
- Pain Intensity(in the last week): Current 8, Best 4, Worst 10, Acceptable
Mr. Lane’s insurance only covers 20 treatment visits for physical therapy. However, the physician ordered physical therapy for five times for two weeks, and then three times per week for six weeks.
Let’s look at the calculation: 5 times a week for 2 weeks, then 3 times a week for 6 weeks equals 28 visits.
He is unable to drive to his appointments due to his pain medications; his wife works during the hours physical therapy is available.
He is having difficulty sleeping due to high pain levels.
Medical History
Recommendations:
Referral to Pain Clinic
Medications
- Atorvastatin 10 mg PO daily
- Lisinopril 10 mg PO daily
- Amlodipine 5 mg PO daily
- Docusate sodium 100 mg PO twice daily
- Oxycodone/acetaminophen 5/325 mg 1-2 every 6 hours PRN severe pain.
Psychosocial
- Insurance concerns
- PT visit limit per insurance; high co-pay
- No OT availability
Work History
No change.
Interventions
Physical Therapy Notes:
- Shoulder AROM (R): 75% of normal motion
- Strength: 4 of 5 in R shoulder; 2 of 5 R elbow
- Grip: 45# R; 125# L
- Pinch: 2 finger pinch 2# R; 8# L
- Swelling R elbow, forearm and hand
- Reflexes: Bicep 2; Triceps 2
- Brachioradialis 1Neurotension: Positive Upper limb tension test (ULT) for ulnar nerve testing
- Sensation: Diminished in area of incision and hypersensitive 4th and 5th digit of right hand Unable to weight bear on RUE
Please see medical record for past medical history. Reason for referral: order for compression garment right upper extremity.
Treatment
Patient was seen status post skin graft right upper extremity 12/4/13. Measurements were taken for fitting of compression garment for the right upper extremity.
Garment was issued with 20mm Hg compression for edema control and for ulnar nerve protection.
Garment is to be worn during waking hours and may be removed at night for skin care. Patient was instructed in use, wear and care of the garment in conjunction with wound dressings. Patient given a home exercise for gentle ROM of the right arm. Patient is to follow-up with physician for monitoring of garment. No Occupational Therapy services available in his home community and will refer to Physical Therapy for care.
Additional Info
Pharmacy Cost: $370.00, Insurance paid $222.00, Out of pocket $148.00
Physical Therapy is 38 visits with $75.00 copay each visit = $2850.00
Activity Event
Assume a Role:
You are a physical therapist.
Situation:
28 physical therapist visits ordered (5 x week for 2 weeks, 3 x week for 6 weeks) but only 20 visits covered by insurance
Problem:
Mr. Lane’s therapy as ordered by the doctor does not cover all the physical therapy visits.
Question: What would be the first step you would do for the physical therapy plan of care to meet his medical needs with a consideration for his finances and insurance?
