Is Your TENS Treatment Worth $750,000?

by Zenobia Knight on November 2, 2021



Many activities performed daily in medical offices become routine. It is important to always follow best practice guidelines—not just occasionally. The Healthcare Providers Service Organization (HPSO) published a review of a physical therapy negligence case in their “HPSO Physical Therapy Spotlight: Burns.” This case resulted in total incurred expenses of approximately $750,000. The case investigation found breaches in the physical therapy standards of care resulting in a decision to settle the case prior to trial.

The Case – What Occurred?

A patient in his early thirties was referred to physical therapy following an arterial bypass procedure on the right leg. The patient’s medical and social history included morbid obesity, diabetes mellitus, chronic leg pain, a sedentary occupation, and tobacco use. Following a twelve-minute transcutaneous electrical nerve stimulation (TENS) treatment, the therapist noticed two round red marks that appeared to be burns. Thinking the burns were not serious, the therapist applied an antibiotic ointment.


The patient was subsequently diagnosed with third-degree burns which required debridement and skin grafts. Two months after the burn injury, the patient was diagnosed with reflex sympathetic dystrophy which negatively impacted the patient’s ability to return to gainful employment. The loss of employment impacted the patient’s health insurance benefits coverage.


Investigative Findings - Standards of Care Failures

  • The therapist failed to perform sensory testing prior to the TENS treatment.
  • The TENS electrodes were noted to be a little worn.
  • The therapist functioned outside the scope of practice by diagnosing and treating burns without an order. The therapist acknowledged applying antibiotic ointment to the burns.

Employer Liability – Does it Exist?

Is there shared liability? The HPSO malpractice claim was filed against the physical therapist and the employer. The therapist stated in their deposition the employer failed to provide training on the TENS manufacturer’s guidelines. The therapist also acknowledged the employer did not have written policies and procedures describing TENS treatment protocols, guidelines, and contraindications.


Lessons Learned from Case

  • Safeguards are needed to ensure clinicians are consistently adhering to best clinical practices when assessing and treating patients.
  • Private practice owners and managers should understand their risks because of the Doctrine Respondeat Superior, which holds an employer liable for the negligent acts of employees when the actions are performed within the scope of employment.
  • Written policies and procedures are needed for treatment and therapeutic modalities utilized by therapists in the clinic. In addition, there should be documented staff training on the policies and procedures to ensure competence.
  • The guidelines on inspecting and testing equipment and related supplies prior to patient use should be clear and the implementation of the guidelines enforced.
  • Clinicians must practice within their scope of practice.
  • Changes in a patient’s condition should be communicated to the referring provider.

According to the “HPSO Physical Therapy Spotlight: Burns,” burns were 16.4 percent of all closed claims in the 2020 claim report dataset. Costs associated with burn claims increased 35.2 percent from the 2016 dataset to the 2020 claims dataset. Some key questions to ask yourself:

  • Do your clinic observations and documentation reviews demonstrate that clinicians are appropriately assessing sensation prior to the application of heat and electrical modalities?
  • Are clinicians adhering to the manufacturer’s guidelines and clinical best practices when administering modalities?
  • Is there adequate patient monitoring during modality treatments?
  • What safeguards does your practice have to minimize risk of malpractice allegations?
  • How comprehensive is your risk management program?
  • Are external auditors and consultants used to help you in identifying areas of risk and ways to mitigate those risks?

How LW Consulting, Inc. Can Help

  • LW Consulting, Inc. (LWCI) conducts clinical documentation audits include billing and coding (ICD-10 and CPT).
    • Regulatory compliance
    • Best clinical practice
  • LWCI conducts scheduling audits to assess risks regarding Impossible Day Scenario billing.
  • LWCI provides appeals and denials consulting support for denied claims for all settings.
  • LWCI assists clients in developing Patient Care Policies and Procedures.
  • LWCI assists clients with developing and conducting Staff Competency Training with Attestation Acknowledgement.
  • LWCI offers a “New Hire Series Training for Outpatient Therapy Providers” which supports the clinic’s New Hire and On-Boarding Policies and Procedures.


LW Consulting, Inc. can assist you with your compliance program and/or conduct a documentation and coding audit. Contact Deborah Alexander at 717-213-3122 or email

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Topics: Compliance