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ChiroCredit.com PresentsCoding and Documentation 202
Documentation Got Documentation?
Presented by
Dr. Gregg Friedman1
Clinical and Practical Documentation
ofChiropractic
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R = Range of Motion Abnormality
Identify an increase or decrease in segmental
mobility using one or more of the following:
• Observation
• Motion Palpation
• Stress Diagnostic Imaging
• Range of Motion Measuring Devices
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Observation(Eyeball Method)
Subjective Interpretation of Subjective Test
Can’t be proven
Can’t show improvement or change
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Motion Palpation
Subjective Interpretation of Objective Test
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Stress Diagnostic Imaging
Flexion/Extension X‐Rays
Without Measurements
Subjective Interpretation of Objective Test
With Measurements
Quantitative Measurement of Objective Test
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Range of Motion Measuring Devices
Goniometer
Single Inclinometer
Dual Inclinometers
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Goniometers
Good for extremities
Not Recommended For the Spine
‐ “the small joints of the spine do not lend themselves readily to two‐arm goniometric measurements and they don’t measure above and below the assessed points.”
AMA Guides to the Evaluation of Permanent
Impairment, 5th Edition, page 400
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Inclinometers
“Inclinometers are recommended by the Guides because the measurements are accurate and reproducible.”
AMA Guides to the Evaluation of Permanent
Impairment, 5th Edition, page 400
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Single vs. Dual Inclinometers
“Since spinal motion is compound, it is essential to measure simultaneously (emphasis added) motion of both the upper and lower extremes of the spine region being examined.”
AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, page 400
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Range of Motion Testing
Cervical Range of Motion Discriminates Between Asymptomatic Persons and Those With Whiplash
SPINE 2001; 26:2090‐2094 (October 1, 2001)
Conclusions: Range of motion was capable of discriminating between asymptomatic persons and those with persistent whiplash‐associated disorders.
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Mercy Guidelines and ROM
“Inclinometers are established for measurements of spinal motion. Their common use is supported by Class I and Class II evidence and is safe and effective.”
Chapter 3, page 46
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ROM – Strength of Recommendation
Type A
Strong positive recommendation. Based on Class I evidence or overwhelming Class II evidence when circumstances preclude randomized clinical trials.
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Computer AssistedRange of Motion Systems
Provide improved levels of precision and reproducibility. They are safe, effective and non‐invasive. They require specialized training and should be interpreted by a qualified health provider.
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Strength of Recommendation Type B
Positive recommendation based on Class II evidence.
Evidence provided by one or more well‐designed uncontrolled, observational clinical studies such as case control, cohort studies, etc.; or clinically relevant basic science studies that address reliability, validity, positive predictive value, discriminability, sensitivity and specificity; and published in refereed journals.
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Reproducible Range of Motion
“The reproducibility (precision) of an individual’s performance is one (but not the sole) indicator of optimumeffort.” AMA Guides, 5th Edition, page 399
‐ three consecutive measurements, calculate the mean
‐ If the average is less than 50˚, three consecutive measurements must fall within 5˚ of the mean; if the average is greater than 50˚, three consecutive measurements must fall within 10% of the mean.
‐may be repeated up to six times to obtain three consecutive measurements that meet these criteria.
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AMA Guides to the Evaluation of Permanent Impairment, 6th Edition
Page 558
“Range of motion is no longer used as a basis for defining impairment, since current evidence does not support this as a reliable indicator of specific pathology or permanent functional status.”
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AMA Guides to the Evaluation of Permanent Impairment, 6th Edition
Page 558
“However, range of motion may be used to monitor clinical progress in individuals.”
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Mercy Guidelines
If a patient does not have signs of objective improvement in any two successive 2 week periods, referral is indicated.
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BAD Documentation of PART Cervical Range of Motion
Flexion 20°
Extension 15°
Left lateral flexion 30°
Right lateral flexion 30°
Left rotation 40°
Right rotation 50°
What’s missing?
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GOOD Documentation of PART
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videos 1 and 2
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Proper Code 95851 (‐59)
Range of Motion Measurements with Report
Each extremity (not hand)
Each trunk (spine) section
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Dual Inclinometers
Manual
‐ least expensive in $, most expensive in time
Electronic/Digital
‐ still manual but more expensive in $, doesn’t
save much time
Computerized
‐ more expensive in $, least expensive in time, may be reimbursable with report
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How To Embarrass a DME(Defense Medical Examiner)
Range of Motion
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Got Documentation?
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Clinical and Practical Documentation
ofChiropractic
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T = Tissue, Tone Changes
Identify using one or more of the following:
• Observation
• Palpation
• Use of instrumentation: document the instrument being used and findings
• Tests for Length and Strength: document leg length, scoliosis contracture, and strength of muscles that relate
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Observation Subjective Interpretation of Objective Test
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Palpation Digital For Tenderness
Subjective interpretation of subjective test (weak documentation)
Pressure Algometry for Tenderness Quantifiable measurement of subjective test (better documentation)
Digital for Spasm Subjective interpretation of objective test (better documentation)
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Tests for Length and Strength
Manual Muscle Testing
Subjective Interpretation of Subjective Test
Muscle Testing w/Dynamometer
Quantitative Measurement of Subjective Test
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Dynamic Surface Electromyography
Quantitative measurement of objective test with an objective interpretation
BEST documentation of soft tissue injury that we have (the Mother Lode)
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Surface Electromyography
Measures electrical impulses generated when a muscle contracts
Functions similar to EKG, but more sensitive
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Static Surface Electromyography
Nerve interference
↓
muscles fire to compensate
↓
abnormal pattern of muscle firing
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Alex Ambroz, MD, MPH
Internationally known expert on low back pain and disability
Board‐Certified in Occupational Medicine
Board of Directors of the American Board of Independent Medical Examiners
Contributor to AMA Guides to the Evaluation of Permanent Impairment, 5th Edition
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According to Ambroz…
Surface EMG is
Inexpensive and non‐invasive method of evaluating spine pain
Evaluates abnormal electrophysiological activity of motor unit
Ambroz et al. showed that both static and dynamic surface EMG can reliably differentiate low back pain patients from controls.
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Outcome Measurements
According to Ambroz, surface EMG is a useful method to document outcomes.
Case Study
Attorney’s Client vehicle struck by school bus
Client not wearing seatbelt, rolled, ejected
Fracture of T7 spinous
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Case Study (continued)
Saw M.D.’s and D.C.’s for tx
Given 7% wpi from neurologist due to fracture
IME orthopedic surgeon agreed with 7%, but all else was normal
Offer from insurance company:
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Case Study (continued)
Attorney sends client to ME
My IME is…NORMAL
One more test…
One abnormal finding
Raised impairment to 14% wpi due to the ONE finding
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Case Study (continued)
Arbitration Award Based On ONE Finding…
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BAD Documentation of PART
Muscle spasm was noted.
Tenderness was noted.
Muscular hypertonicity was noted.
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GOOD Documentation of PART(Daily Visits)
Muscle spasms were noted in the left trapezius, right levator scapulae and bilateral supraspinatus muscles.
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Cervical Flexion - during this motion, the left and right cervical paraspinal and sternocleidomastoid (SCM) muscles should be relaxing together while in the fully flexed position, contracting together when returning to the neutral position and relaxing together when in the neutral position. The results of this test revealed: The paraspinal muscles continued to contract while in the fully flexed position, which is abnormal. The paraspinal muscles continued to contract when returned to the neutral position, which is abnormal. The SCM muscles continued to contract with the neck in the fully flexed position, which is abnormal.
GOOD Documentation of PART(Exams)
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videos 3 and 4
The PART Systemof Documentation (cont’d)
HCFA/CMS requires that at least 2 of the 4 components (P, A, R, T) MUST be documented, and at least one of A or R
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Initial Visit Requirements
Relevant History of Patient’s Condition
Evaluation of Musculoskeletal/Nervous System through physical exam
Diagnosis
Treatment Plan: duration and frequency of visits, specific treatment goals, objective measures to evaluate treatment effectiveness
Date of Initial Treatment
4848
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Subsequent Visit Requirements
History
Review of Chief Complaint
Improvement or regression since last
visit
System Review, if relevant
4949
Subsequent Visit Requirements (continued)
Physical Examination
Exam of the spine involved in diagnosis
Assessment of change in patient
condition since last visit
Evaluation of treatment effectiveness
5050
Subsequent Visit Requirements (continued)
Documentation of Treatment Given on Day of Visit
Any Changes to the Treatment Plan
5151
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Got Documentation?
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Clinical and Practical Documentation
ofChiropractic
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SOAP vs. PART
Subjective
P – Pain/Tenderness
Objective
A – Asymmetry/Misalignment
R – Range of Motion Abnormality
T – Tissue/Tone Changes
Assessment
Plan
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Assessment
How is the patient responding to care?
Since the last visit or prior exam
For each condition
Complicating Factors Patient Characteristics – i.e. age, non‐compliance, obesity
Injury Characteristics – i.e. severe signs/symptoms
History – i.e. pre‐existing pathology
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S.O.A.P. Assessment:
Guarded
Good
Improving
Same
Regressing
Exacerbated
MMI/Static and Stationary
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video 5
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Plan
2 types of Plan
Treatment Plan after exams
Frequency
Duration
Goals for Each Condition
What Objective Measures Will You Use to Monitor Treatment Effectiveness?
Treatment Plan for daily visits
What did you do on that visit?
Times for timed codes
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S.O.A.P.
Plan:
Spinal Adjustments
Extremity Adjustments
Passive Modalities
Therapeutic Procedures (Active Rehab)
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Therapeutic Procedures
Manual Therapy (97140)
‐ performed in order to increase functional performance, increase range of motion, decrease inflammation and reduce muscle spasms
‐ one unit equals 8 to 22 minutes
‐ key components: what, where, why, how long
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Therapeutic Procedures
Therapeutic Exercise (97110)
‐ performed in order to develop strength and endurance, range of motion and flexibility
‐ one unit equals 8 to 22 minutes
‐ key components: what, where, why, how long
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Therapeutic Procedures
Neuromuscular Re‐Education (97112)
‐ performed in order to improve movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities
‐ one unit equals 8 to 22 minutes
‐ key components: what, where, why, how long
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More About Plan
At Exams and Re‐Exams Visit Frequency and Duration Goals of Treatment Re‐evaluations
Prescriptions Home exercises Pillow Exercise ball Traction device
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Bad Plan
Chiropractic Adjustments Were Performed.
Manual Therapy Was Performed.
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Good Plan
Chiropractic adjustments were performed to hypomobile subluxations at C3, C7, T4, T5, L3 and L5.
Manual therapy was performed for 10 minutes to the left levator scapulae muscle in order to increase functional performance, increase range of motion, decrease inflammation and reduce muscle spasms.
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Videos 6 and 7
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Medicare Diagnoses
According to CMS, the level of subluxation must be specified on the claim as the PRIMARY DIAGNOSIS.
The neuromusculoskeletal condition necessitating the treatment must be listed as the SECONDARY DIAGNOSIS.
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Primary ICD10 Diagnoses
M99.00 Segmental and Somatic Dysfunction of Head Region (some states)
M99.01 Segmental and Somatic Dysfunction of Cervical Region
M99.02 Segmental and Somatic Dysfunction of Thoracic Region
M99.03 Segmental and Somatic Dysfunction of Lumbar Region
M99.04 Segmental and Somatic Dysfunction of Sacral Region
M99.05 Segmental and Somatic Dysfunction of Pelvic Region
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Secondary ICD 10 Diagnoses(generally require short‐term treatment)
Headaches
Spondylosis with myelopathy
Spondylosis with radiculopathy
Spondylosis w/out myelopathy or radiculopathy
Ankylosing hyperostosis
Cervicalgia
Pain in thoracic spine
Low back pain
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Secondary ICD 10 Diagnoses(generally require moderate‐term treatment)
Plexus disorders
Root disorders
Nerve root disorders
Pain in unspecified joint
Spondylolisthesis
Fusion of spine
Torticollis
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Secondary ICD 10 Diagnoses(generally require moderate‐term treatment)
Spinal enthesopathy
Spinal stenosis
Disc disorder with radiculopathy
Disc disorders
Cervicocranial syndrome
Radiculopathy
Muscle spasm of back
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Secondary ICD 10 Diagnoses(generally require moderate‐term treatment)
Myalgia
Fibromyalgia
Osseous stenosis
Intervertebral disc stenosis
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Secondary ICD 10 Diagnoses(generally require longer term treatment)
Disc displacement
Disc degeneration
Sciatica
Lumbago with sciatica
Post‐laminectomy
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Videos 8 and 9
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Medicare
Exacerbations
Date of Onset
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Medicare Audit Triggers
Same Diagnoses For All Patients
Onset Date Doesn’t Change
98940, 98941, 98942 frequency of use
Required Elements of the history and exam absent
Treatment Plan – lacked specific and measurable goals
Missing or incomplete P.A.R.T. elements
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