Differentiating Maintenance Care vs. Supportive Care€¦ · Differentiating Maintenance Care vs....

DifferentiatingDifferentiatingMaintenance Care vs. Supportive CareMaintenance Care vs. Supportive Care


Remember the results of the 2005 OIG report Remember the results of the 2005 OIG report ““Chiropractic Services in the Medicare Program: Chiropractic Services in the Medicare Program: payment Vulnerability Analysispayment Vulnerability Analysis””? One of the main issues ? One of the main issues was billing for maintenance services:was billing for maintenance services:

Maintenance ServicesMaintenance Services““Maintenance servicesMaintenance services were the most common were the most common type of noncovered chiropractic services that type of noncovered chiropractic services that Medicare paid for in 2001Medicare paid for in 2001””57% of all services billed were deemed 57% of all services billed were deemed maintenance services.maintenance services.


Most health plans offer chiropractic coverage as a core Most health plans offer chiropractic coverage as a core benefit for its members. Typically the benefit doesnbenefit for its members. Typically the benefit doesn’’t t cover chiropractic services that are experimental, cover chiropractic services that are experimental, investigational of unproven efficacy or care considered investigational of unproven efficacy or care considered maintenance care. Understanding the terms maximum maintenance care. Understanding the terms maximum medical improvement, maximum therapeutic benefit, medical improvement, maximum therapeutic benefit, supportive care and maintenance care is crucial in supportive care and maintenance care is crucial in todaytoday’’s 3rd party reimbursement system. It can help you s 3rd party reimbursement system. It can help you avoid audit and recovery processes or being investigated avoid audit and recovery processes or being investigated by the OIG which can carry hefty fines and potential by the OIG which can carry hefty fines and potential licensing board sanctions.licensing board sanctions.


Before we can discuss the difference between Before we can discuss the difference between maintenance care and supportive care, we need maintenance care and supportive care, we need to review some definitions:to review some definitions:

Maximum Medical Improvement (MMI)Maximum Medical Improvement (MMI)A condition that has reached a clinical end point at A condition that has reached a clinical end point at which no significant improvement in the baseline which no significant improvement in the baseline can be reasonably anticipated. For most patients, can be reasonably anticipated. For most patients, their conditions have either completely resolved, or their conditions have either completely resolved, or no longer require supervised intervention.no longer require supervised intervention.


Maximum Therapeutic Benefit (MTB)Maximum Therapeutic Benefit (MTB)The application of the present therapeutic regimen has achieved The application of the present therapeutic regimen has achieved its full potential for the episode of this condition for which iits full potential for the episode of this condition for which it was t was applied.applied.If the condition has plateaued (reached MTB), and the patient If the condition has plateaued (reached MTB), and the patient continues to have significant complaints, objective findings andcontinues to have significant complaints, objective findings andfunctional deficits, itfunctional deficits, it’’s appropriate to consider:s appropriate to consider:1.1. Changing the current treatment approach such as increasing the Changing the current treatment approach such as increasing the

therapeutic exercise plan (active care) in lieu of or in additiotherapeutic exercise plan (active care) in lieu of or in addition to a n to a predominantly passive care plan (e.g., traction).predominantly passive care plan (e.g., traction).

2.2. Discuss self management with the patient including lifeDiscuss self management with the patient including life--style style modifications, injury avoidance, and then discharge the patient modifications, injury avoidance, and then discharge the patient or or transition into elective care (self pay).transition into elective care (self pay).

3.3. Referring the patient for consultation and possibly a different Referring the patient for consultation and possibly a different therapeutic approach.therapeutic approach.

4.4. Reviewing the clinical status of the case to determine if supporReviewing the clinical status of the case to determine if supportive tive care is necessary.care is necessary.


Supportive CareSupportive CareTreatment/care of patients having reached maximum therapeutic Treatment/care of patients having reached maximum therapeutic benefit (MTB), in whom periodic trials of therapeutic withdrawalbenefit (MTB), in whom periodic trials of therapeutic withdrawals fail s fail to sustain previous therapeutic gains that would otherwise to sustain previous therapeutic gains that would otherwise progressively deteriorate.progressively deteriorate.Supportive care is Supportive care is inappropriateinappropriate when it interferes with other when it interferes with other appropriate primary care options or when the risk of supportive appropriate primary care options or when the risk of supportive care care outweighs its benefits, i.e. physician dependence, somatization,outweighs its benefits, i.e. physician dependence, somatization,illness behavior or secondary gain.illness behavior or secondary gain.Supportive care follows appropriate application of active and Supportive care follows appropriate application of active and passive care including lifestyle modifications.passive care including lifestyle modifications.

Too many clinicians attempt to transition their patients into Too many clinicians attempt to transition their patients into supportive or as needed care without fully understanding the supportive or as needed care without fully understanding the parameters for supportive care. Letparameters for supportive care. Let’’s look at the criteria that s look at the criteria that justifies supportive care.justifies supportive care.


Criteria for Supportive CareCriteria for Supportive CareSupportive care may be appropriate when:Supportive care may be appropriate when:

The patient is at maximum medical improvement (MMI)The patient is at maximum medical improvement (MMI)The patient has been afforded alternative care options prior to The patient has been afforded alternative care options prior to or or after chiropractic care to reach MMI. These may include but are after chiropractic care to reach MMI. These may include but are not not limited to medication, physical therapy, exercises, pain limited to medication, physical therapy, exercises, pain management, etc.management, etc.There is documented controlled trials of treatment withdrawal, wThere is documented controlled trials of treatment withdrawal, which hich results in significant deterioration of the patientresults in significant deterioration of the patient’’s condition (not just s condition (not just symptoms but also activities of daily living). The use of objectsymptoms but also activities of daily living). The use of objective ive outcome tools (Oswestry Low Back Index and Neck Disability Indexoutcome tools (Oswestry Low Back Index and Neck Disability Index) ) are useful to measure any deterioration in the patients functionare useful to measure any deterioration in the patients functional al activities. Therefore, the notes have to indicate that the patieactivities. Therefore, the notes have to indicate that the patient was nt was conditionally released with selfconditionally released with self--care instructions (activity care instructions (activity modifications, exercises). modifications, exercises). The treatment is rendered on an asThe treatment is rendered on an as--needed basis in response to an needed basis in response to an exacerbation. The visits are not preexacerbation. The visits are not pre--scheduled. and do not exceed 3 scheduled. and do not exceed 3 visits over a 2visits over a 2--month period.month period.


Maintenance CareMaintenance CareSome insurance carriers may cover supportive care Some insurance carriers may cover supportive care while others may not. Almost no carriers cover while others may not. Almost no carriers cover wellness/preventive care for chiropractic services. wellness/preventive care for chiropractic services. This is what is typically called This is what is typically called ““maintenance care.maintenance care.””MedicareMedicare’’s definition is: A treatment plan that seeks s definition is: A treatment plan that seeks to prevent disease, promote health and prolong and to prevent disease, promote health and prolong and enhance the quality of life, or therapy that is enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a performed to maintain or prevent deterioration of a chronic condition. Once MTB has been achieved for a chronic condition. Once MTB has been achieved for a given condition, ongoing maintenance therapy is not given condition, ongoing maintenance therapy is not considered to be medically necessary.considered to be medically necessary.


Maintenance CareMaintenance CareThe promotion of preventative care or wellness is a The promotion of preventative care or wellness is a core belief in chiropractic. However there is little core belief in chiropractic. However there is little scientific literature to support maintenance care. With scientific literature to support maintenance care. With the chiropractic profession adopting an evidence the chiropractic profession adopting an evidence based approach to care, maintenance care at this based approach to care, maintenance care at this time remains elective. Because maintenance care time remains elective. Because maintenance care does not meet the criteria of medical necessity (most does not meet the criteria of medical necessity (most health plans have a provider manual with medical health plans have a provider manual with medical necessity defined) itnecessity defined) it’’s a non covered service.s a non covered service.


Maintenance CareMaintenance CareSo in general maintenance care is a form of elective care So in general maintenance care is a form of elective care (treatment chosen by the patient after MMI or MTB has been (treatment chosen by the patient after MMI or MTB has been reached) whereby a patient presents with any of the following reached) whereby a patient presents with any of the following and chooses to obtain treatment:and chooses to obtain treatment:

Absent symptoms and/or objective findingsAbsent symptoms and/or objective findingsWith a request for With a request for ““wellness carewellness care”” or or ““preventative servicespreventative services”” in order in order to maximize general health and well being.to maximize general health and well being.With residual complaints, objective findings and/or functional With residual complaints, objective findings and/or functional restrictions that do not substantially deteriorate with an absenrestrictions that do not substantially deteriorate with an absence of ce of supervised intervention.supervised intervention.

Clinicians that choose to provide nonClinicians that choose to provide non--covered elective services covered elective services (e.g. maintenance care) may be able to do so under a self(e.g. maintenance care) may be able to do so under a self--pay pay agreement directly with the patient (agreed to prior to treatmenagreement directly with the patient (agreed to prior to treatment t rendered). Itrendered). It’’s the responsibility of the clinician to ensure that s the responsibility of the clinician to ensure that only benefit eligible clinical services are billed to 3rd party only benefit eligible clinical services are billed to 3rd party payors.payors.


Sample Chart Entries:Sample Chart Entries:Supportive CareSupportive Care

A 56 yearA 56 year--old male is 4 years postold male is 4 years post--laminectomy at L4laminectomy at L4--L5. He has had a L5. He has had a course of physical therapy and chiropractic care. The patient recourse of physical therapy and chiropractic care. The patient reached MMI ached MMI and was released with home exercise instruction and activity modand was released with home exercise instruction and activity modifications ifications and was instructed to return on an as needed basis two months agand was instructed to return on an as needed basis two months ago. He o. He presents today for an exacerbation of a stable condition due to presents today for an exacerbation of a stable condition due to excessive excessive snow shoveling 2 days ago. The Oswestry disability index indicatsnow shoveling 2 days ago. The Oswestry disability index indicates the es the patient finds it difficult to sit for greater than 30 minutes anpatient finds it difficult to sit for greater than 30 minutes and walk greater d walk greater than 1 mile without pain. The patient presented with minimal symthan 1 mile without pain. The patient presented with minimal symptoms. The ptoms. The patient was treated today with spinal manipulation along with repatient was treated today with spinal manipulation along with reviewing his viewing his exercise protocol and other selfexercise protocol and other self--care instructions. The patient responded care instructions. The patient responded well to the treatment. The patient has been able to selfwell to the treatment. The patient has been able to self--manage with home manage with home activities and was instructed to return on an as needed basis.activities and was instructed to return on an as needed basis.

Maintenance CareMaintenance Care““Patient returns today for routine monthly visit. Minimal complaiPatient returns today for routine monthly visit. Minimal complaints of nts of stiffness. However patient would like a stiffness. However patient would like a ““tunetune--upup”” to prevent regression to to prevent regression to how she was when she started care. We are treating today as usuahow she was when she started care. We are treating today as usual and l and schedule her for a follow up in 1 month.schedule her for a follow up in 1 month.””

CMT CodingCMT Coding

CMT CodingCMT CodingRemember the results of the 2005 OIG report Remember the results of the 2005 OIG report ““Chiropractic Services in the Medicare Program: Chiropractic Services in the Medicare Program: payment Vulnerability Analysispayment Vulnerability Analysis”” ??

16% of all services were miscoded or billed at the 16% of all services were miscoded or billed at the incorrect level of spinal manipulation.incorrect level of spinal manipulation.6% of all services billed were undocumented.6% of all services billed were undocumented.Upcoding was a significant problem, resulting in $15 Upcoding was a significant problem, resulting in $15 million overpayment.million overpayment.

69% of CPT code 98942 billed were upcoded69% of CPT code 98942 billed were upcoded21% of CPT code 98941 billed were upcoded21% of CPT code 98941 billed were upcoded

So what is appropriate CMT coding?So what is appropriate CMT coding?

CMT CodingCMT CodingA challenge often experienced by clinicians is choosing A challenge often experienced by clinicians is choosing procedure codes that most accurately reflect their procedure codes that most accurately reflect their patients condition and the services that are provided for patients condition and the services that are provided for their patients. Constantly changing guidelines, their patients. Constantly changing guidelines, misinterpretations, and improper documentation of misinterpretations, and improper documentation of clinical necessity in order to receive appropriate clinical necessity in order to receive appropriate reimbursement can make choosing the correct codes reimbursement can make choosing the correct codes even more of a challenge.even more of a challenge.

CMT CodingCMT CodingItIt’’s extremely important when billing 3s extremely important when billing 3rdrd party payors that the party payors that the appropriate level of CMT billed is supported by the patientappropriate level of CMT billed is supported by the patient’’s s presenting complaint. Practitioners presenting complaint. Practitioners ““techniquetechnique”” or or ““philosophyphilosophy”” is is not a relevant factor in determining the level of manipulation tnot a relevant factor in determining the level of manipulation to bill o bill to a 3to a 3rdrd party payor.party payor.If your clinical notes are ever audited to compare billing and If your clinical notes are ever audited to compare billing and payment accuracy and the medical necessity of your services, payment accuracy and the medical necessity of your services, supporting documentation for manipulation and adjunct therapy tosupporting documentation for manipulation and adjunct therapy to a a region (s) should include:region (s) should include:1.1. A patient that presents with a symptomatic health problem in theA patient that presents with a symptomatic health problem in the form form

of a neuromusculoskeletal conditionof a neuromusculoskeletal condition2.2. Presence of a subluxationPresence of a subluxation3.3. Clinical signs and symptoms consistent with the levels of subluxClinical signs and symptoms consistent with the levels of subluxationation4.4. A direct therapeutic relationship to the patientA direct therapeutic relationship to the patient’’s condition, ands condition, and5.5. Provide reasonable expectation of recovery or improvement of Provide reasonable expectation of recovery or improvement of

function.function.

CMT CodingCMT CodingFor purposes of CMT, there are 5 spinal regions. For purposes of CMT, there are 5 spinal regions. These are:These are:

CervicalCervicalIncludes atlantoIncludes atlanto--occipital joint, C1occipital joint, C1--77

ThoracicThoracicIncludes cosovertebral/costotransverse joints (posterior ribs), Includes cosovertebral/costotransverse joints (posterior ribs), T1T1--1212

LumbarLumbarIncludes L1Includes L1--55

SacralSacralSacrum, including sacrococcygeal jointSacrum, including sacrococcygeal joint

PelvicPelvicSacroiliac joint and pelvic articulationSacroiliac joint and pelvic articulation

5

1

2

3

4

CMT CodingCMT Coding

3 CMT codes were developed to 3 CMT codes were developed to encompass the 5 spinal regions:encompass the 5 spinal regions:

CMT 98940CMT 98940Spinal, one to two regionsSpinal, one to two regions

CMT 98941CMT 98941Spinal, three to four regionsSpinal, three to four regions

CMT 98942CMT 98942Spinal, five regionsSpinal, five regions

CMT CodingCMT CodingClinical ExamplesClinical Examples

The following clinical examples are intended to give the cliniciThe following clinical examples are intended to give the clinician an examples of clinical situations and appropriate use of CMT codesexamples of clinical situations and appropriate use of CMT codes, , but is in no way intended to describe every manipulative procedubut is in no way intended to describe every manipulative procedure re of clinical scenario.of clinical scenario.

CMT 98940CMT 98940A 45 yearA 45 year--old male, established patient, presents with a old male, established patient, presents with a complaint of rightcomplaint of right--sided cervicothoracic pain for 2 days after sided cervicothoracic pain for 2 days after carrying groceries. After a complete examination, manipulation carrying groceries. After a complete examination, manipulation to the cervical (C5) and thoracic (T2) regions was performed andto the cervical (C5) and thoracic (T2) regions was performed anddocumented.documented.

CMT CodingCMT CodingClinical ExamplesClinical Examples

CMT 98941CMT 98941A 69 yearA 69 year--old female, established patient, presents with a main old female, established patient, presents with a main complaint of headaches with associated cervicothoracic pain and complaint of headaches with associated cervicothoracic pain and secondary upper lumbar pain. After examining the patient you finsecondary upper lumbar pain. After examining the patient you find d subluxations/joint restrictions at C4, T2, L3, and L5. Manipulatsubluxations/joint restrictions at C4, T2, L3, and L5. Manipulation was ion was performed at these levels. Note the 98941 code was appropriate wperformed at these levels. Note the 98941 code was appropriate with ith the patient presenting with 3 areas of complaint.the patient presenting with 3 areas of complaint.

CMT 98942CMT 98942A 47 yearA 47 year--old male, established patient, presents after a fall from a old male, established patient, presents after a fall from a ladder at home. You had the patient complete a Ransford Pain Dialadder at home. You had the patient complete a Ransford Pain Diagram gram which supports his subjective complaints and your examination which supports his subjective complaints and your examination (objective) findings at the cervical, thoracic, lumbar, sacroili(objective) findings at the cervical, thoracic, lumbar, sacroiliac and ac and buttocks, bilaterally. Manipulation was administered to the cervbuttocks, bilaterally. Manipulation was administered to the cervical (C5), ical (C5), thoracic (T7,8,9), costotransverse joint T9, lumbar (L4,5), sacrthoracic (T7,8,9), costotransverse joint T9, lumbar (L4,5), sacroiliac and oiliac and sacrococcygeal joints.sacrococcygeal joints.

XX--Ray Report WritingRay Report Writing

XX--Ray Report WritingRay Report WritingMany practitioners consider writing x-ray reports to be too time consuming and onerous. As a result, they either write a brief summary of their impressions or make no written report at all. Not making a report is comparable to performing a physical examination and not documenting the tests or results in the patient’s record.

So why complete an x-ray report?, there are a number of important reasons and purposes:

XX--Ray Report Writing Ray Report Writing –– Why?Why?

1.1. Professional ResponsibilityProfessional Responsibility2.2. Medicolegal IssuesMedicolegal Issues3.3. ComparisonComparison4.4. Permanent RecordPermanent Record5.5. CommunicationCommunication6.6. Indications/contraindicationsIndications/contraindications

XX--Ray Report WritingRay Report WritingProfessional ResponsibilityProfessional Responsibility

Each clinician interpreting a study is responsible for Each clinician interpreting a study is responsible for everything on that study. Therefore, iteverything on that study. Therefore, it’’s important that we s important that we be able to construct accurate, concise and meaningful be able to construct accurate, concise and meaningful reports. Remember, as with all aspects of the patientreports. Remember, as with all aspects of the patient’’s s file, the xfile, the x--ray report is a reflection of the abilities and ray report is a reflection of the abilities and professionalism of the practitioner.professionalism of the practitioner.

XX--Ray Report WritingRay Report WritingMedicoMedico--Legal IssuesLegal Issues

Often it’s the report, rather than the film or verbal opinion, that serves as the legal document in any legal proceeding.

XX--Ray Report WritingRay Report WritingComparisonComparison

Comparing a recent report with previous reports or Comparing a recent report with previous reports or radiographs can be useful when the radiographs:radiographs can be useful when the radiographs:

Have been lost, destroyed or unavailableHave been lost, destroyed or unavailableAre very numerousAre very numerousInformation is urgently needed. The report can be Information is urgently needed. The report can be electronically transferredelectronically transferredPrevious report can direct a current investigation and Previous report can direct a current investigation and interpretation to a specific site or type of abnormality (ie. interpretation to a specific site or type of abnormality (ie. changes in size of a lesion).changes in size of a lesion).

XX--Ray Report WritingRay Report WritingComparisonComparison

Consider the following situation:Consider the following situation:

A 52 yearA 52 year--old male presents with midold male presents with mid--thoracic pain and a productive thoracic pain and a productive cough. The pain has been worsening over the past 3 weeks. You decough. The pain has been worsening over the past 3 weeks. You decide cide that a chest xthat a chest x--ray is appropriate because of the potential ray is appropriate because of the potential red flagred flag of of infection or cancer. Upon reviewing the xinfection or cancer. Upon reviewing the x--ray, a wellray, a well--defined round defined round opacity measuring 1 cm is seen in the right upper lobe along witopacity measuring 1 cm is seen in the right upper lobe along with a wellh a well--defined infiltrate in the middle lobe. Luckily, you were able todefined infiltrate in the middle lobe. Luckily, you were able to obtain a obtain a copy of the patientcopy of the patient’’s previous xs previous x--ray reports. A report written 2 years ray reports. A report written 2 years previous also described the same lesion in the same location andprevious also described the same lesion in the same location and same same size. Given that it has not changed in size over this timesize. Given that it has not changed in size over this time--frame, it most frame, it most likely represents a benign lesion such as a calcified granuloma.likely represents a benign lesion such as a calcified granuloma. The The wellwell--defined infiltrate you determine is most likely pneumonia and ydefined infiltrate you determine is most likely pneumonia and you ou make the appropriate referral.make the appropriate referral.

Hence, a previous report can direct a current investigation and Hence, a previous report can direct a current investigation and interpretation to a specific site or type of abnormality (ie. chinterpretation to a specific site or type of abnormality (ie. changes in size anges in size of a lesion). Please refer to the red flag download at this timof a lesion). Please refer to the red flag download at this time. e.

XX--Ray Report WritingRay Report WritingPermanent RecordPermanent Record

When radiographs are lost, disposed of or not available, When radiographs are lost, disposed of or not available, the report remains part of the patientthe report remains part of the patient’’s permanent s permanent record. Where a patientrecord. Where a patient’’s file is extensive and other s file is extensive and other studies have been conducted over time, the xstudies have been conducted over time, the x--ray report ray report can provide substantive information as to any preexisting can provide substantive information as to any preexisting conditions.conditions.

XX--Ray Report WritingRay Report WritingCommunicationCommunication

Provides useful information to any other healthcare Provides useful information to any other healthcare practitioner involved in the patientpractitioner involved in the patient’’s care or future care. It s care or future care. It may also be used for communication with any 3rd party may also be used for communication with any 3rd party payors. Hence, it serves to facilitate interprofessional payors. Hence, it serves to facilitate interprofessional and intraprofessional communication.and intraprofessional communication.

XX--Ray Report WritingRay Report WritingIndications/ContraindicationsIndications/Contraindications

By providing a status review of the patientBy providing a status review of the patient’’s condition, s condition, clear management directions can occur, ie. rule out any clear management directions can occur, ie. rule out any contraindications. Also remember to link the history and contraindications. Also remember to link the history and exam findings with the xexam findings with the x--ray findings as there is a high ray findings as there is a high incidence of xincidence of x--ray features that are unrelated to the ray features that are unrelated to the patientpatient’’s complaint.s complaint.

Medicolegal ImplicationsMedicolegal ImplicationsPitfalls of ReportsPitfalls of Reports

Sources of medicolegal problems with xSources of medicolegal problems with x--ray reports are numerous. These can be ray reports are numerous. These can be minimized when a standard reporting format is followed, the repominimized when a standard reporting format is followed, the report is completed rt is completed with as little distraction as possible, when adequate time is alwith as little distraction as possible, when adequate time is allocated, and when located, and when you carefully proofread all reports before signing and/or transmyou carefully proofread all reports before signing and/or transmitting somewhere.itting somewhere.

Some of the pitfalls include:Some of the pitfalls include:

Failure to produce a reportFailure to produce a reportWhenever an xWhenever an x--ray is taken or any film obtained from outside your clinic, a reray is taken or any film obtained from outside your clinic, a report should port should be generated. Without this, the inference could be made that thebe generated. Without this, the inference could be made that the study was not study was not interpreted or included as part of the patientinterpreted or included as part of the patient’’s management. Did you miss something on s management. Did you miss something on the film?the film?

Patient details omittedPatient details omitted•• Details include patient name, address, gender, date of birth, anDetails include patient name, address, gender, date of birth, and any relevant clinical d any relevant clinical

information. This ensures the patient is clearly and correctly iinformation. This ensures the patient is clearly and correctly identified.dentified.Failure to describe study detailsFailure to describe study details

•• Failure to provide study details can be a medicolegal trap. DefiFailure to provide study details can be a medicolegal trap. Defining what studies were ning what studies were reviewed and when they were taken ensures that the opinions onlyreviewed and when they were taken ensures that the opinions only relate to those and relate to those and nothing else. Itnothing else. It’’s also important to note if no right or left markers are visibles also important to note if no right or left markers are visible. .

•• If you are reviewing an outside film, did you mention the qualitIf you are reviewing an outside film, did you mention the quality of the study?y of the study?


MisdiagnosisMisdiagnosisMistakes can occur for a number of reasons. This can be due to fMistakes can occur for a number of reasons. This can be due to failure to recognize ailure to recognize something as an abnormality or a normal variant, failure to searsomething as an abnormality or a normal variant, failure to search fully even after one ch fully even after one abnormality is found, and failure to detect a lesion at the periabnormality is found, and failure to detect a lesion at the periphery of the study. A great phery of the study. A great reference text to use if you interpret your own films is: reference text to use if you interpret your own films is: ““Keats Atlas of Normal VariantsKeats Atlas of Normal Variants””..

Failure to suggest further studiesFailure to suggest further studiesIf there are findings that suggest a significant abnormality thaIf there are findings that suggest a significant abnormality that needs a followt needs a follow--up or up or different views or referral for more advanced imaging and itdifferent views or referral for more advanced imaging and it’’s not performed, this could s not performed, this could have legal, not to mention health, ramifications.have legal, not to mention health, ramifications.

Failure to report study adequacyFailure to report study adequacyImage quality has a direct bearing on your ability to diagnosticImage quality has a direct bearing on your ability to diagnostically read the film. A failure ally read the film. A failure to denote right or left should also be noted. If you are dictatito denote right or left should also be noted. If you are dictating a report on an inferior ng a report on an inferior quality film note that in the report (ie the films are underexpoquality film note that in the report (ie the films are underexposed).sed).


ConfidentialityConfidentialityRemember release of the report should be accompanied by the patiRemember release of the report should be accompanied by the patientent’’s permission. This s permission. This can be obtained with written consent.can be obtained with written consent.

Failure to follow recommendationsFailure to follow recommendationsIf specific recommendations were made, then follow through with If specific recommendations were made, then follow through with them. If not, provide them. If not, provide clear, wellclear, well--documented reasons why this was not done.documented reasons why this was not done.

Failure to review previous reportsFailure to review previous reportsSignificant information may be found on previous reports. That iSignificant information may be found on previous reports. That information may help nformation may help direct the present review to focus in on a particular area (i.e.direct the present review to focus in on a particular area (i.e. previous report discuss what previous report discuss what appears to be a benign lesion. The new film can be used to compaappears to be a benign lesion. The new film can be used to compare the lesions present re the lesions present size etc..size etc..


Creating xCreating x--ray reports is an integral part of clinical practice. ray reports is an integral part of clinical practice. Developing skill in their formation requires an adequate Developing skill in their formation requires an adequate environment, equipment, interpretive skill, and knowledge base.environment, equipment, interpretive skill, and knowledge base.

Being aware of the errors inherent in the interpretation of studBeing aware of the errors inherent in the interpretation of studies is ies is important. These are due to analysis of poor studies, lack of important. These are due to analysis of poor studies, lack of knowledge, perceptual errors, reading just the reports and not tknowledge, perceptual errors, reading just the reports and not the he film, and failure to access a second opinion if needed. Rememberfilm, and failure to access a second opinion if needed. Remember, if , if a film comes in with a report, look at the film, dona film comes in with a report, look at the film, don’’t just rely on the t just rely on the report itself. Failure to provide a report or a report that is ireport itself. Failure to provide a report or a report that is inaccurate naccurate as part of the patientas part of the patient’’s record is a legal liability.s record is a legal liability.

SummarySummaryIn this age of accountability and medicolegal requirements, clinIn this age of accountability and medicolegal requirements, clinical ical records can become a clinicianrecords can become a clinician’’s best defense tool or their worst s best defense tool or their worst enemy.enemy.Maintaining high standards in documentation ensures excellence iMaintaining high standards in documentation ensures excellence in n both professional practices and patient care. Appropriate both professional practices and patient care. Appropriate documentation has relevance to patients, practitioners, the documentation has relevance to patients, practitioners, the profession and 3profession and 3rdrd party payors. party payors. Information obtained during the initial and subsequent patient vInformation obtained during the initial and subsequent patient visits isits helps lay the foundation for justifying treatment, diagnostic tehelps lay the foundation for justifying treatment, diagnostic tests and sts and concurrent care protocols. Information collected should be in anconcurrent care protocols. Information collected should be in anorganized format (whether itorganized format (whether it’’s the classic s the classic SOAPSOAP or a modification of or a modification of the SOAP format) that allows information to be recorded in a the SOAP format) that allows information to be recorded in a predictable manner using specific headings. Whatever format you predictable manner using specific headings. Whatever format you use be consistent and thorough. use be consistent and thorough.

SummarySummaryAs we learned from the 2005 OIG Report As we learned from the 2005 OIG Report ““Chiropractic Services in Chiropractic Services in the Medicare Program: payment Vulnerability Analysisthe Medicare Program: payment Vulnerability Analysis””, we must , we must have a heightened consciousness around record keeping, have a heightened consciousness around record keeping, maintenance care, goal setting and coding. In this age of maintenance care, goal setting and coding. In this age of accountability we need to know what is billable to a 3accountability we need to know what is billable to a 3rdrd party payor party payor and what the difference is between maintenance care and and what the difference is between maintenance care and supportive care.supportive care.We also must be diligent in billing the appropriate CMT coding, We also must be diligent in billing the appropriate CMT coding, not not based on our beliefs but based on clinical presentation. Remembebased on our beliefs but based on clinical presentation. Remember r that the OIG Report pointed out that after reviewing Chiropractithat the OIG Report pointed out that after reviewing Chiropractic c records:records:

Upcoding was a significant problem, resulting in $15 million oveUpcoding was a significant problem, resulting in $15 million overpayment.rpayment.69% of CPT code 98942 billed were upcoded69% of CPT code 98942 billed were upcoded21% of CPT code 98941 billed were upcoded21% of CPT code 98941 billed were upcoded

SummarySummaryThis module also provided a documentation This module also provided a documentation checklist. This form can be used to self audit your checklist. This form can be used to self audit your record keeping procedures by applying this record keeping procedures by applying this checklist to a random patient file in your office. checklist to a random patient file in your office. Applying what you have learned here into clinical Applying what you have learned here into clinical practice can save you headaches down the road.practice can save you headaches down the road.Remember:Remember:

““Your records are your best defense tool or your worst enemyYour records are your best defense tool or your worst enemy””

Thanks for attending. We hope you Thanks for attending. We hope you found this course useful. Donfound this course useful. Don’’t forget t forget to take Parts 2 and 3 of this series on to take Parts 2 and 3 of this series on

Documentation Best PracticeDocumentation Best Practice

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