Medicare and the Chiropractic Practice, Part 3

Meeting Medicare’s Documentation Requirements

By Susan McClelland, BS, CCA

Documentation continues to be the chiropractic profession’s greatest weakness when it comes to Medicare reimbursement. A major focus of the Chiropractic Summit meetings has been to advance efforts for improving Medicare documentation.

For a service to be reimbursable through Medicare, the documentation must show clinical necessity for the patient’s care. There are several essential elements for required Medicare documentation, including demonstrating a subluxation and thoroughly documenting both the initial visit and each subsequent visit.

Demonstrating a Subluxation

A subluxation may be demonstrated by either an X-ray or by physical examination using the PART criteria (see below). If an X-ray is used to document the subluxation, it must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific X-ray evidence is warranted, an X-ray is considered reasonably proximate if it was taken no more than 12 months prior to, or three months following, the initiation of the course of chiropractic treatment.

To demonstrate a subluxation based on the physical examination, two of the four PART criteria (pain/tenderness, asymmetry/misalignment, range-of-motion abnormality and tissue, tone changes) are required, one of which must be either asymmetry/misalignment or range-of-motion abnormality.

• Pain and tenderness must be documented in terms of location, quality and intensity. Examples of ways pain may be identified include noting antalgic gait or pain-avoidance postures; noting if pain is reproduced while examining the patient – “Let me know if this causes discomfort”; having the patient mark their pain on a scale from 0-10; asking the patient to verbally grade their pain from 0-10; and using questionnaires such as the McGill pain questionnaire.
• Asymmetry/misalignmentmay be identified on a sectional or segmental level. Examples of ways asymmetry/misalignment can be identified include observing the patient’s posture or analyzing gait, static palpation and diagnostic imaging.
• Range-of-motion abnormality represents changes in active, passive and accessory joint movements, resulting in an increase or decrease of sectional or segmental mobility. Abnormalities can be identified via several methods: observing an increase or decrease in the patient’s ROM; motion palpation to identify “fixed” segments; X-raying the patient using bending views; and utilizing goniometers or inclinometers.
• Tissue tone changes represent alterations in the characteristics of contiguous and associated soft tissues including skin, fascia, muscle and ligament. Tissue changes can be identified by observing tissue tone, texture and temperature for spasm, inflammation, swelling and/or rigidity; palpating hypertonicity, hypotonicity, spasm, tautness, rigidity, and/or flaccidity; and testing for scoliosis contracture and/or muscle strength.
  Remember, identifying a subluxation by using the PART criteria requires identifying at least two of the four PART components through physical examination. In addition, one of those two must be “A” (asymmetry/misalignment) or “R” (range-of-motion abnormality).

Initial and Subsequent Visits

The following elements should be documented at initial and subsequent office visits in order to meet Medicare documentation requirements:

The Initial Visit

• Date of first visit
• History: statement of general health (including vital signs); family history, if relevant; past health history (prior injuries/traumas, prior surgeries, prior hospitalizations and current medications); contraindications; description of present illness (symptoms causing patient to seek treatment – must bear a direct causal relationship to the level of subluxation); mechanism of trauma; quality and character; onset, duration, intensity, frequency, location and referral/radiation; aggravating and relieving factors; and prior interventions, treatments, and medications); and secondary complaints
• Physical evaluation
• Diagnosis: primary (required to be subluxation for Medicare reimbursement) and secondary (must be a neuromusculoskeletal condition with a direct causal relationship to the primary diagnosis)
• Treatment plan: recommended level of care (duration and frequency of visits), specific treatment goals and objective measures to evaluate treatment effectiveness
• Signature/initials (legal requirement to authenticate records)

Subsequent Visits

Date of subsequent visit

History: review of chief complaint, changes since last visit, system review if relevant

Physical exam: examination of area of spine involved in diagnosis; assessment of change in patient condition since last visit

Evaluation: Assessment of treatment effectiveness

Treatment given on day of visit

Signature/initials (legal requirement to authenticate records)

For additional information on improving Medicare documentation, members of the profession are urged to access the Summit Steering Committee-endorsed “Proper Medicare Documentation” Webinar, available free of charge at www.acatoday.org/online.

The Chiropractic Summit is an ongoing collaborative process through which participants seek common solutions and formulate collective action steps to address several challenges facing the chiropractic profession, including Medicare and the upcoming national debate on system-wide health reform. Thus far, there have been five summit meeting, the latest of which involved representatives from 35 chiropractic organizations, including membership organizations, educational institutions, and research and public education foundations, who gathered in Washington, D.C., in May 2009. Meetings and related activities take place under the auspices of a broad-based steering committee comprised of representatives of the four major participating organizations: Dr. Carl Cleveland III, past president, Association of Chiropractic Colleges (ACC); Dr. Lewis Bazakos, former board chair, American Chiropractic Association (ACA); Dr. John Maltby, president, International Chiropractors Association (ICA); and Dr. Jerry DeGrado, president, Congress of Chiropractic State Associations (COCSA).

Changes may put therapists out of work

There is the fear that scores of aromatherapists, reflexologists and massage therapists will be put out of business if proposed changes to the registration of therapeutic health practitioners go ahead.

The Allied Health Professions Council of South Africa (AHPCSA) wants to petition the minister of health to change legislation so that the term “therapeutic” is removed from the names of the professions of aromatherapy, massage therapy and reflexology.

This means people in these fields would be known as practitioners. They would also have to register with the health council.

Tracy Chambers of the SA Association of Health and Skincare Professionals said this would influence the entire industry, as anyone wanting to practise reflexology or aromatherapy would have to comply with council regulations.

The council has said the reason for the change was to prevent people from practising as therapeutic therapists without registering with them.

Chambers said the distinction between therapeutic – meaning that it was used for healing – and non-therapeutic treatments was misleading, as both required the same knowledge.

Registered therapeutic practitioners would also be barred from offering treatment in any circumstances other than medical referrals.

“It impinges hugely on the industry,” Chambers said.

Gayl Hansen, director of the Cape Institute for Allied Health Studies, said the proposed changes did not look at the “bigger picture” of the need for basic skills at grassroots levels.

There is speculation that practitioners wanting to register with the AHPCSA would have to do a four-year degree – meaning they could practise on a clinical level.

“This is very short-sighted,” Hansen said.

She said the council needed to have multiple levels of entry and training in the health care industry so that therapists with basic training could still work in beauty salons.

Therapists with clinical training tended to work for themselves, not in a spa or beauty salon.

However, the non-registered therapist without clinical training, but with the skills to do reflexology or massage therapy, would be unable to practise.

Debbie Drake-Hoffmann, the registrar of the AHPCSA, said the change would not put therapists without clinical training out of business.

“On the contrary, if spas employed registered therapists it would ensure the public received standardised quality treatments.”

She said current legislation prevented council-registered practitioners from working for health spas or beauty salons, but the council was reviewing these regulations.

The deadline for comments on the AHPCSA’s proposed changes is July 31.

This article was originally published on page 3 of The Star on June 19, 2008

3 Sure-Fire Strategies to Prevent the Swine Flu

Dr. M.J. Wegmann

Dr. Wegmann is the co-founder of one of the fastest growing health website in the world.

With today’s headlines dominated by the swine flu we need to learn more in order to protect ourselves and our families. The 1918 Flu killed an estimated 40 million people world wide. I pray this outbreak does not reach that proportion. I cannot comprehend the psychological impact of death on this scale in society today.

Here’s a little history on the swine flu.

On February 5, 1976, an army recruit died and four of his fellow soldiers were later hospitalized. Two weeks after his death, health officials announced that swine flu was the cause of death and that this strain of flu appeared to be closely related to the strain involved in the 1918 flu pandemic.

On August 20, 2007 Department of Agriculture officers investigated the outbreak of swine flu in Nueva Ecija and Central Luzon, Philippines.

In March and April 2009, more than 1,000 cases of swine flu in humans were detected in Mexico, and more than 100 deaths are suspected to have a connection with the virus. The Mexican fatalities are said to be mainly young adults, a hallmark of pandemic flu. [1]

The nature of a flu tends to be in waves. Flu pandemics typically come in waves. The 1889-1890 and 1918-1919 flu pandemics each came in three or four waves of increasing lethality. [2] I can’t find much information about what wave this flu is on, but researchers are more concerned about this flu than many in the past.

Here are 3 Sure-fire Strategies to help you and your family respond to the threat of the flu.

1. Hygiene- maybe one of the greatest advances of the industrialized nations was the change in the way sanitation and hygiene were practiced. Limiting our exposure to toxins both organic and inorganic makes sense. The body has a built in immune system, but sometimes that system can be overwhelmed. Frequent hand washing, especially when there has been contact with other people or with potentially contaminated surfaces can be very helpful.

2. Chiropractic- One of the most important studies was performed by Ronald Pero, Ph.D., chief of cancer prevention research at New York’s Preventive Medicine Institute and professor of medicine at New York University. It showed the positive effect that chiropractic care can have on the immune system and general health.

Dr. Pero measured the immune systems of people under chiropractic care as compared to those in the general population and those with cancer and other serious diseases. His initial three-year study was of 107 individuals who had been under chiropractic care for five years or more. The chiropractic patients were found to have a 200% greater immune competence than those people who had not received chiropractic care, and they had 400% greater immune competence than those people with cancer and other serious diseases. The immune system superiority of those under chiropractic care did not appear to diminish with age. Dr. Pero stated:

When applied in a clinical framework, I have never seen a group other than this chiropractic group to experience a 200% increase over the normal patients. This is why it is so dramatically important. We have never seen such a positive improvement in a group. [3]

Another study from Patricia Brennan, Ph.D., leading a team of researchers, conducted a study that found improved immune response in her test subjects following chiropractic treatment. The study specifically demonstrated the “phagocytic respiratory burst of polymorphonuclear neutrophils (PMN) and monocytes were enhanced in adults that had been adjusted by chiropractors.” [4]

Life Chiropractic University, produced an incredible study from the Sid Williams Research Center in 1994. The researchers took a group of HIV positive patients and adjusted them over a six-month period. What they found was that the “patients that were adjusted had a forty-eight percent (48%) increase in the number CD4 cells (an important immune system component).” These measurements were taken at the patients’ independent medical center, where they were under medical supervision for the condition. The control group (the patients that were not adjusted) did not demonstrate this dramatic increase in immune function, but actually experienced a 7.96% decrease in CD4 cell counts over the same period. [5]

The immune system is affected by the nerve system through the connections with the endocrine and the autonomic nervous system. And chiropractic care improves the function of the nerve system through improving the movement of the spinal bones that encase and protect the spinal cord.

Stressful conditions lead to altered measures of immune function, and altered susceptibility to a variety of diseases. Many stimuli, which primarily act on the central nervous system, can profoundly alter immune responses. The two routes available to the central nervous system are neuro-endocrine channels and autonomic nerve channels. [6]

3. Masks- no mask can provide a perfect barrier but products that meet or exceed the NIOSH N95 standard are thought to provide good protection. The rationale behind masks is to limit airborne secretions to stop the virus from spreading from person to person. The use of masks is not uncommon in the hospitals where the potential of infection can be greater in compromised patients. It would be unethical and potential deadly for a surgeon to operate without first washing their hands and using a mask.

As I stated previously I pray this flu does not turn pandemic. Millions of people’s lives will be at stake. I do hope you adopt some of the ideas I shared with you; starting first with the hygiene. Second I encourage you to explore the wonders of chiropractic if you currently know little about chiropractic. Finding a great chiropractor can be a challenge. Many chiropractors simply operate as “pain” doctors, never fully utilizing or understanding the miraculous results when applied properly.

Dr. Wegmann is the co-founder of TheNewWellness.com one of the fastest growing health websites in the world.

[1]. Deadly new flu virus in US and Mexico may go pandemic”. New Scientist. 24 April 2009.

[2]. U.S. Institute of Medicine; Stacey L. Knobler, Alison Mack, Adel Mahmoud, Stanley M. Lemon (editors) (2005). The Threat of Pandemic Influenza:

[3]. Pero R. “Medical Researcher Excited By CBSRF Project Results.” The Chiropractic Journal, August 1989; 32.

[4]. [4] Brennan P, Graham M, Triano J, Hondras M. “Enhanced phagocytic cell respiratory bursts induced by spinal manipulation: Potential Role of Substance P.” J Manip Physiolog Ther 1991; (14)7:399-400.

[5]. [5] Selano JL, Hightower BC, Pfleger B, Feeley-Collins K, Grostic JD. “The Effects of Specific Upper Cervical Adjustments on the CD4 Counts of HIV Positive Patients.” The Chiro Research Journal; 3(1); 1994.

[6] Felton DL, Felton SY, Belonged DL, et al. “Noradrenergic sympathetic neural interactions with the immune system: structure and function.” Immunol Rev. 1987 Dec;100:225-60.

Getting A Feel For A Chiropractic Career

Chiropractic is a form of health care that focuses on the relationship between the structure of the spine and the body’s function. Also called chiropractors or chiropractic physicians, they use a type of hands-on therapy consisting of manipulation of the bones and joints as their core clinical procedure. This career field manages to do quite well without calling a great deal of attention to itself, and if you are good with your hands and want to get into medical practice but want to specialize in a field and not take so much time in school, perhaps the chiropractic career is right for you.

How’d it start?
The word “chiropractic” combines the Greek words cheir (hand) and praxis (action) and means “doing it by hand.” Chiropractic is considered an alternative medical system and takes a different approach from conventional medicine in diagnosing, classifying, and treating medical problems.

Chiropractic has a long and distinguished lineage. Chiropractic was first described by Hippocrates in ancient Greece. Chiropractic came to us in it’s present-day form via Daniel David Palmer, who in 1895 founded the modern profession of chiropractic in Davenport, Iowa. Palmer was a student of healing philosophies of the day. It was his observation that the body has a natural healing ability that is controlled by the nervous system, that misalignments of the spine interfere with the body’s natural operation which itself was a concept borrowed from osteopathic traditions, and that one could develop a procedure to adjust the bones of the spinal column with the goal of correcting it’s setting.

What kind of training do I need?
Most chiropractic training is a four year academic course consisting of both classroom and clinical instruction. At least three years of preparatory college work are required for admission to most chiropractic schools. Students who graduate receive the degree of Doctor of Chiropractic and are eligible to take state license board examinations in order to practice. Some schools also offer postgraduate courses, including residency programs in specialized fields lasting two to three years.

Chiropractic practice is regulated individually on a state-by-state basis. Most states require chiropractors to earn continuing education credits in order to maintain their licenses. Chiropractors’ scope of practice varies by state. It can include performing laboratory tests or diagnostic procedures, the dispensing or selling of dietary supplements, and even the use of acupuncture or homeopathy. Chiropractors are not licensed in any state to perform major surgery or prescribe drugs.

Who is the typical patient?
About 200 million Americans visit chiropractors per year. Nearly half of those visits are to treat back or neck pain. Of these, some are chronic sufferers and some are the result of accidents. Conditions commonly treated by chiropractors include back pain, neck pain, headaches, sports injuries, and repetitive strain injuries. Patients also seek treatment of pain associated with other conditions, such as arthritis.

Low-back pain is a common medical problem, occurring in up to one-fourth of the population each year. Most people experience significant back pain at least once during their lifetime. Often, the cause of back pain is unknown, and it varies greatly in terms of how people experience it and how professionals diagnose it. This makes back pain challenging to study, given that the spine is such a complex system of bone, cartilage, and nerve tissue.

What kinds of treatments to chiropractors provide?
Typically, the chiropractor will perform a physical examination, with special emphasis on the spine, and possibly other diagnostic examinations such as Xrays. A treatment plan is then developed.

Treatment of the patient typically includes manipulation treatment. This is a manual therapy. Given mainly to the spine, chiropractic adjustments involve applying a controlled force to a joint. These are done to increase the range and quality of motion in the area being treated. Other health care professionals such as physical therapists, sports medicine doctors, orthopedists, physical medicine specialists, doctors of osteopathic medicine, and massage therapists perform various types of manipulation. However, chiropractors perform over 90 percent of manipulative treatments within the field.

Chiropractors may use other treatments in addition to adjustment, such as mobilization, massage, and non-manual treatments. These last may be any of heat and ice, ultrasound, electrical stimulation, rehabilitative exercise dietary supplements, or even acupuncture. A chiropractor may also provide counseling about diet, weight loss, and other lifestyle factors.

Is chiropractic regarded as “real” medicine?
It most definitely is for back and neck pain and treatment of migraine headaches. Clinical studies have reinforced that the treatment works. But chiropractic is still seen as an “alternative” medical practice, and some other medical fields regard the practice with some skepticism. Frequently this skepticism comes from the tendency for some practitioners to branch off into homeopathy, aromatherapy, magnetic therapy, and other fringe theory venues.

Because chiropractic practice is still fighting for acceptance, it is suggested that the chiropractor stick to the practice as “by the book” and only practice proven effective techniques. Leave the New Age stuff to the psychics.

Are there studies showing the effectiveness of chiropractic?
In 1998, a study of 10,652 Florida workers’ compensation cases was conducted. It was concluded that a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled. If already disabled, the patient tends to remain disabled for a shorter period of time. Claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors!

Going further back, a 1991 study of Oregon Workers’ Compensation Claims examined randomly selected workers’ compensation cases that involved disabling low-back injuries. It found that when individuals with similar injuries were compared, those who visited chiropractors generally missed fewer days of work than those who visited other kinds of doctors.

In 1989, a survey in the state of Washington concluded that patients receiving care from health maintenance organizations were three times as likely to report satisfaction with care from chiropractors as they were with care from other physicians. The patients were also more likely to believe that their chiropractor was concerned about them. This goes to show that the “hands-on” approach of chiropractic has at least some benefit.

Chiropractic study frequently focuses on treating the “whole patient” and getting to the root cause of a problem instead of merely treating the symptoms. This makes perfect sense to some minds and is only dimly grasped by others. Perhaps it takes a special kind of person to do chiropractic right. If you’re one of those people, a career as a chiropractor could prove to be a rewarding and successful choice.

Josh Stone

http://www.articlesbase.com/careers-articles/getting-a-feel-for-a-chiropractic-career-72327.html

Chiropractic: The Natural Way To Pain Relief

by Igor Mandaley

In a rush of publicity, a number of drugs like Vioxx were taken off the market. The reason was that they were said to increase the risk of heart attack. Then it was Celebrex’s turn to be carefully evaluated due to the identical concerns. Now the focus is back on anti-inflammatory medication.

The Journal of Gastroenterology and Hepatology reported a recent study’s finding that non-steroidal anti-inflammatory drugs (NSAIDS) produced greater intestinal harm than formerly believed.

If there was ever was a time for a more natural option like chiropractic treatment for ordinary pain symptoms that time is definitely now. If you or a family member are using any of these medications for spinal issues, send this to them and inform them about chiropractic right now.

The total yearly expenses related to treatment of low back pain (LBP) in the U.S. have been estimated at around $100 billion. Great rates of recurrence and long-term disability are thought to play a big part in the total expense of back pain, and research has indicated that just a fraction of LBP sufferers stay free of pain and totally recover, just a single year from the initial occurrence.

A study recently conducted followed 30 patients with a history of at least 6 months of chronic, non-specific low back pain. They were placed into two different groups. The first group were given 12 treatments in one month, but no treatments in the following nine months; the next group were given 12 treatments over one month, and an addition “maintenance spinal manipulation” every three weeks for the next nine months.

Results: Patients in both of the groups noticed considerable decreases in lower back pain scores after completing the first round of treatments. The most obvious discrepancy was noticed in disability scores throughout the study.

Based on these results, it is apparent that regular chiropractic care is not only helpful in the reduction of LBP, and disability lined with LBP, but also that continuous chiropractic treatment following the acute treatment stage helps in keeping the pain from occurring again. Your chiropractic doctor can create a treatment plan that will relieve your pain if you suffer from lower back pain, or any similar problem.

About the Author:

Cremorne Family Chiropractic is run by Jeff BenMayor, a North Shore Sydney Chiropractor with over 9 years experience. If you need a Chiropractor in North Shore Sydney, call (02) 9908 2235.