A good first step in understanding the value of peer review to the profession and to the PT or PTA being reviewed is to become familiar with peer review terminology.
A system by which peers with similar areas of expertise and like licensure assess the physical therapy care provided, using accepted practice standards and guidelines. The guiding principles of peer review are to educate physical therapists to:
- Uphold professional standards,
- Be accountable to the public, and
- Be consistent in interactions with peers, colleagues, and payers.1
Clinical Practice/Utilization Review
A system for reviewing the medial necessity, appropriateness, and reasonableness of services proposed or provided to a patient or group of patients. This review is conducted on a prospective, concurrent, and/or retrospective basis to reduce the incidence of unnecessary and/or inappropriate provision of services.
Utilization review has 2 primary purposes: to improve the quality of services (and patient outcomes) and to ensure efficient use of financial resources.
Internal Peer Review
Review by the physical therapist of his or her own service provision or the services provided by peers within the same facility, practice, clinic, or other setting. Internal peer review may result in self-improvement by an individual physical therapist, physical therapist assistant, or physical therapist service.1
External Peer Review
Review by a physical therapist outside of a facility, private practice, clinic, or other setting of services provided by 1 or more physical therapists within that entity, at the request of the facility, a payer, a medical review organization, a professional organization, or a regulatory agency. External peer review may result in a quality assurance review, determination of medical necessity or appropriateness of care, or determination of fair payment.1
Review of the billing record and related documentation and treatment records that may result in identification of issues requiring medical review.
Review of the medical record based on standards of practice in regard to medical necessity and appropriateness of care.
A person of the same profession who is like-licensed.
Physical Therapist Service
A facility, clinic, private practice or other setting where PTs and PTAs provide physical therapist services. Also refers to the professional service(s) delivered by PTs and PTAs.
The Institute of Medicine (IOM) defines quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."2 The terminology is carefully chosen to include all points along the continuum of care. IOM also identifies 3 basic quality-of-care issues in medicine: overuse, underuse, and misuse.
APTA's position on Quality Assurance and Performance Improvement advocates voluntary member participation in quality assurance and performance improvement activities that are incorporated into daily practice, stating that the commitment to quality assurance and performance improvement is primarily a professional responsibility.
Physical Therapy Record Review
A review of the clinical documentation.
Prospective Record Review
Conducted prior to the onset of a service or treatment. This can also be referred to as precertification review or prior authorization. This review usually is performed in relation to utilization management.
Concurrent Record Review
Conducted during an ongoing course of treatment or episode of care.
Retrospective Record Review
Conducted after services have been provided.
- American Physical Therapy Board of Directors. Guidelines: Peer Review Training (BOD G03-05-15-40). Alexandria, VA: American Physical Therapy Association; 2005.
- Crossing the Quality Chasm: A New Health System for the 21st Century.