QuickSOAP*Touchnotes

Is Patient Education Worth the Time?

Is Patient Education Worth the Time?

by Dr. David Bohn, DC

Chiropractors will talk about educating patients and never question that an educated patient is more likely to begin care and then stick with a recommended care plan. When many chiropractors elect to educate their patients they usually fail to do it in a creative way that attracts and holds attention, answers the questions that really need answered, yet do not nag or annoy their patient.

People today are not like the patients of the 1980’s. Attention spans are shorter, information on any topic is available with just the click of a mouse, and the competition to be noticed and heard is fierce.

This presents a dilemma. If we all agree that if our patient is educated about their problem and the solution we are offering results in a less stressful practice for us and a better outcome for the patient why isn’t this happening?

Perhaps I can offer an example from my own life to help illustrate. 

As an undergraduate college student I drank and apparently enjoyed low cost beer, sometimes to excess. I knew very little about how beer was brewed and really wouldn’t have cared to have it explained. Beer was important to me for the same reasons it is to all 21-year-old men. In chiropractic school a friend of mine introduced me to home brewing. I read every book I could find, spoke with people in the local shop that sold home brewing supplies and eventually mastered understood the importance of understanding the importance of balling degrees and terminal gravity. As the years past my interest and understanding in beer grew to the point that I cannot bring myself to drink a can of mass produced swill that many people find so satisfying.

Well enough about beer, here’s the moral to the story. The more you learn about something, the more interested you become in it and the more of it you begin to buy. You buy more and become more loyal to it until you become a valuable lifetime customer of the product. I will admit to you, I am now a loyal lifetime Samuel Smith’s Oatmeal Stout raving fan although I still enjoy experiencing fine microbrews as I travel. Applying this to chiropractic means that the better you educate your patient, the better client they will be, the more loyal they will be to your practice, the more money they will spend, and most importantly the better they will be able to explain your practice and what you do to their friends and family. This means you will get more referrals and have a better, less stressful practice.

It all comes down to increasing the value of each patient. Not just for 18-24 visits but for the lifetime of that patient, for the referrals and the new problems they may have over their lifetime.

Patient education;

1.   Increase the number of internal referrals your practice receives.

2.   Increases the PVA (patient visit average) of each patient because educated patients comprehend the value of chiropractic.

3.   Educated patients understand the value of maintenance.

4.   They are more likely to remain long term patients in your practice and educated patients are less concerned about fees.

My personal favorite example of quality, creative patient education is the take home report of findings. This would include copies of the patient’s x-rays with lines drawn on it demonstrating the patient’s biomechanical faults. Pictures of the patient preforming each range of motion. A posture analysis showing the patient the abnormalities. A listing of their subluxated segments with the corresponding effected organs and muscles, and a financial case presentation. I also like to provide the patient a copy of their first visit note in narrative format. This take home report allows the patient to fully understand and share their problem and my solutions will everyone.

Dr. David Bohn, DC is the founder of http://www.chiroconceptions.com and has been practicing chiropractic since 1988. For more information on software and other tools to increase your practice visit our website or call 301-777-3710 for more information.

EHR Stimulus Funds for Chiropractic Note Programs

On July 16, 2010 the “Final Rule” regarding Meaningful Use criteria and EHR (Electronic Health Records) Financial Incentives was released and has generated  lots of questions and a lot of confusion for many chiropractors about how to obtain stimulus dollars for documentation software (EHR/EMR). Several times a week a chiropractor will ask me if my program QuickSOAP Notes (www.chiroconceptions.com) meets the requirements.

Here are what I believe are the key points regarding EHR eligibility for those of you who don’t care to read the original documents or fact sheets on Meaningful Use and EHR Financial Incentives in their entirety:

• Meaningful Use Criteria which establish eligibility for financial incentives are for EHR Certified programs only. Translation: if your EHR is not certified, you may not receive any financial stimulus.  Many EHR companies are advertising that they are “eligible” for certification, although this is not the same as being certified.  Buyer beware!

• You know only need to complete 20 of the 25 Meaningful Use Objectives/Measures as defined in the Final Rule issued by CMS.  Even though you may “defer” 5 of these requirements, this is still an ambitious list for most practitioners in order to qualify for the funds.

• The completion of these Objectives/Measures fulfills Stage 1 requirements only (which make you eligible for the financial incentive portion).  Stage 2 and Stage 3 objectives exist, but the exact requirements and penalties are not as well defined.

• Chiropractors are Eligible Professionals that may qualify for the EHR financial incentives

• Chiropractors may be eligible for EHR financial incentive payments as early as 2011; payments can proceed for up to 5 years.

• The total financial payments that chiropractors are eligible to receive is a maximum of  $44,000 over a 5 year period or equal to 75% of Medicare allowable charges for covered professional services furnished by the chiropractor in an eligible year.  This is perhaps the biggest criteria EHR companies fail to mention.  In other words, in one given year, you can receive up to $18,000 IF (and only if) you provide at least $24,000 worth of covered services (based on allowable charges) to Medicare patients.  On the other hand, if you have a small Medicare practice, your eligible financial incentives will be reduced accordingly and capped at 75% of the allowable charges for your covered services (which, in chiropractic, is CMT only).  Do the math to see if your practice qualifies for anywhere near the $44K amount.

The Bottom Line

My feelings have not been changed by the “final rule” criteria.  I would highly recommend that most offices switch to some form of electronic health records.  However, this advice is NOT based on the presumption that you are doing so to capture any potential financial stimulus incentives.  Rather, migrate to EHR because of its potential to improve your documentation, level of care and overall record-keeping. I would add that you should search for a program that you WILL USE and not for the best deal or all in one package.

Tips for Properly Billing Chiropractic Codes

When doing your billing consider these tips:

1. All E/M chiropractic codes should have a -25 modifier (i.e 99201-25, 99211-25) when billed with other services

2. All 98943 (extremity adjustments) should have a different diagnosis linked to it than the 98940-2 (spinal adjustment codes). For example, 98941—— 739.1, 739.2; 98943——— 739.7

3. 97140 and 97112 must have a ‘59’ modifier.

4. 97140 must have a different diagnosis than the diagnosis for the adjustment code (98940-3). The diagnosis must be on different areas (regions) of the body.

5. Sequence Billing
1st service ——E/M or OV (99201-99205; 99211-99215)
2nd service ————-Diagnostic (x-rays) (7000 codes)
3rd service——Spinal Adjustment (98940, 98941, 98942)
4th service———————-Extremity Adjustment (98943)
5th service—PT service by dollar amount (97000 Codes)

6. Diagnosis Pointing - When billing out insurance claims, you will usually have more than one diagnosis on the form. When you have more than one CPT (procedure) code, and more than one ICD-9 (diagnosis) code, you need to match them correctly. On the HCFA box 21, there are 4 places to put your ICD-9 codes. In box 24E, there is a place to ‘point your diagnosis’. Be specific and only put the code(s) from box 21 the diagnosis that apply to that particular service you provided. You may use all four of the codes for a particular service; however that may not be the case each time.

7. Medicare - All ‘98’ codes must have ‘AT’ modifier, unless service is considered maintenance. In which case, Medicare does not allow payment for maintenance care. All other services must have the ‘GY’ modifier to indicate this is a nonpayable service. The ‘GP’ modifier is used on all physical therapy codes. The ‘GA’ modifier is used to indicate that you have a completed and signed ABN (Advanced Beneficiary Notice) on file.

Are You Giving Your Services Away?

Most chiropractors are performing a great deal of services that they are not billing for. You should bill and get paid for the services that you perform. You may be able to increase your reimbursement by $100-$200 per visit and you are giving the service away by not properly billing. You can do this by simply using the appropriate Chiropractic codes. Here are some examples:

Examples of services with high RVU (Relative Value Units)

*97110 - Therapeutic exercises to develop strength, endurance, range of motion and flexibility (i.e. stair stepper, stationary bike, exercise ball)

*97112 Neuromuscular Re-education of movement, balance, kinesthetic sense, posture (i.e. wobble board, balance board, wobble chair, exercise ball)

*97140 Manual Therapy as defined by CPT, manipulations, manual lymphatic drainage. Manual therapy applied to the soft tissue to increase joint range of motion, restore joint integrity and improve overall performance

*97535 Self Care Home Management Training

These codes are billed per units. One unit is equivalent to 15 minutes. Be sure that you have documented the time spent on each service. You must use the -59 modifier to CPT code 97140 when billing this service in addition to the adjustment code.

Now add any of the above mentioned services to your adjustment code and you will see how much you have been giving away.

Be sure that your fee schedule is appropriate for your geographical region. Having an outdated or inappropriate fee schedule is costly.

Chiropractic vs. Physical Therapy. If you are performing physical therapy services and the patient has reached the maximum benefits allowed for chiropractic services, you may be able to receive payment for the physical therapy services that you are performing. When verifying insurances, be sure to ask if these services (Chiropractic and Physical Therapy) will be reimbursed separately. Whether or not the DC is able to perform PT services may vary from state to state. Be sure to check with your Chiropractic Board to be certain.

Medicare Chiropractic Codes

Billing Medicare can be confusing for a new chiropractor and sometimes for an established chiropractor.

Coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (i.e., by use of hands) of the spine for the purpose of correcting a subluxation. For the purpose of Medicare Chiropractic codes, a subluxation is defined as a motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered, although contact between the joint surfaces remain intact. The patient must have a subluxation of the spine as demonstrated by x-ray or physical examination.

Keep in mind that x-rays are considered noncovered when billed by the chiropractor. No other diagnostic or therapeutic services furnished by a chiropractor or under his or her order is covered. This means if a chiropractor orders, takes or interprets x-rays or any other diagnostic test, the x-ray or diagnostic test can be used for claims processing purposes, but Medicare coverage and payment are not available for these services.

ICD-9-CM Codes that Support Medical Necessity

The CPT/HCPCS codes included in this policy will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as “not medically necessary.”

Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:

Primary Diagnosis Codes
Covered for:

739.0-739.5
Non-allopathic lesions, not elsewhere classified

Secondary Diagnosis Codes
Group A Diagnoses
Covered for:

307.81
Tension headache
719.48
Pain in joint, other specified sites
Note:
When using this code, you must specify spine.
723.1
Cervicalgia
724.1-724.2
Other and unspecified disorders of back
724.5
Backache, unspecified
724.8
Other symptoms referable to back
728.85
Spasm of muscle
784.0
Headache

Group B Diagnoses
Covered for:

720.1
Spinal enthesopathy
721.0 - 721.2
Spondylosis and allied disorders (arthritis, osteoarthritis, spondyloarthritis)
724.79
Disorders of coccyx, coccygodynia
729.1
Myalgia and myositis, unspecified
729.4
Fasciitis, unspecified
846.0
Sprains and strains of sacroiliac region, lumbosacral (joint)(ligament)
846.1 - 846.3
Sprains and strains of sacroiliac region
846.8
Sprains and strains of sacroiliac region, other specified sites of sacroiliac region
847.0 - 847.4
Sprains and strains of other and unspecified parts of back

Group C Diagnoses
Covered for:

353.0-353.4
Nerve root and plexus disorders
353.8
Other nerve root and plexus disorders
722.91-722.93
Other and unspecified disc disorder
723.0
Spinal stenosis in cervical region
723.2-723.5
Other disorders of cervical region

Group D Diagnoses
Covered for:

721.3
Lumbosacral spondylosis without myelopathy
721.41 - 721.42
Lumbosacral spondylosis with myelopathy
721.7
Traumatic spondylopathy
722.0
Displacement of cervical intervertebral disc without myelopathy
722.10-722.11
Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.4
Degeneration of cervical intervertebral disc
722.51-722.52
Degeneration of thoracic or lumbar intervertebral disc
722.81-722.83
Postlaminectomy syndrome
724.01-724.02
Spinal stenosis, other than cervical
724.3
Sciatica
724.4
Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.6
Disorders of sacrum, ankylosis
738.4
Acquired spondylolisthesis
756.11 - 756.12
Anomalies of spine
839.01 - 839.08
Other, multiple and ill-defined dislocations, cervical vertebra,
839.20 - 839.21
Other, multiple and ill-defined dislocations, thoracic and lumbar vertebra, closed
839.41 - 839.42
Other, multiple and ill-defined dislocations, other vertebra, closed
953.0 - 953.4
Injury to nerve roots and spinal plexus

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements

Documentation supporting the medical necessity of the service should be legible, maintained in the patient’s medical record, and must be made available to Medicare upon request.
Please see Medicare Benefit Manual sections referenced above for national documentation requirements for Medicare payment of chiropractic services.

Utilization Guidelines
Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

12 chiropractic manipulation treatments for Group A diagnoses.
18 chiropractic manipulation treatments for Group B diagnoses.
24 chiropractic manipulation treatments for Group C diagnoses.
30 chiropractic manipulation treatments for Group D diagnoses.
Claims for chiropractic services that exceed the numbers above may be subjected to complex manual medical review either prior to payment or as part of a post-pay Medicare audit.

The AT modifier must be used when a patient is being treated for an acute treatment. If you do not use the AT modifier, the services will be considered maintenance and will therefore be denied.

QuickSOAPnotes from www.chiroconceptions.com makes documenting a Medicare visit easy and fast.

Here’s what to look for when reviewing your documentation.

When it came to discussing medical documentation, here are some fundamental suggestions on how to make the insurance process work more smoothly:

* Don’t ignore a request for records. The sooner they’re received, the quicker the reimbursement process moves.

* Sometimes the codes do not correlate. For example if you use ICD-9 for “lumbago.” That’s non-specific for the level of trauma. The CPT code, too, may be non-specific.

* Notes need to be legible, of good quality, and sufficiently (but not overly) detailed.

* Don’t worry about random text generation so much. How many ways can you say “I drive a Ford Explorer”? My point is that there are only so many ways to say that you adjusted C7.

* Always ask yourself, is this care reasonable and necessary? Is it related? Reviewers need to know the doctor’s prognosis and treatment plan. Many times the carrier will have no problem if the treatment goes beyond the original estimation of the length of time needed, but they need to see the doctor’s goals and plan of care updated.

* The treatment plan allows the insurer to know whether to approve payment or ask for information. Reviewers are trained to read the SOAP format and expect to see reevaluations on a regular basis.

* Claims adjusters are on the lookout for cases that diverge from the original treatment plan to the point where they say, “There’s something wrong here.” That includes patient improvement or regression -key elements for the adjuster to know.

Pain Related to Bad Weather Conditions

If you seem to have increased pain when the weather goes bad then you may find this medical study interesting.

Weather Conditions and Spinal Patients Spine: Volume 29(12), June 15, 2004, pp 1369-1373 Glaser, John A. MD; Keffala, Valerie PhD; Spratt, Kevin PhD

FROM ABSTRACT Study Design: A retrospective study. Objectives. To evaluate the effects of various weather conditions on reported health status. Methods. Initial visit data from 23 American centers participating in the National Spine Network included demographic information and SF-36-based health status. Weather conditions when and where patients were seen were obtained from the National Climatic Data Center and U.S. Naval Observatory. SF-36 outcomes were predicted using multiple regression techniques from weather parameters, which included high and low temperature, average dew point, wet bulb, barometric pressure, total precipitation, phase of the moon, and length of sunlight. Results. A total of 26,862 patients were evaluated. Barometric pressure was the only weather predictor that was consistently significant. Increased pressure was associated with worse outcomes. Although age and gender were significant additions to the prediction equation, overall, the practical contribution was minimal. Conclusion. A statistically significant relationship between weather factors and SF-36-based health status exists.

THESE AUTHORS ALSO NOTE: “Musculoskeletal pain is frequently mentioned as being sensitive to variations in climate.” “The most commonly implicated climatic variables are high humidity, cold temperature, and low barometric pressure, interestingly all indicative of impending storms.” 2 “Several studies have been published on generalized pain, joint pain, and activity level in response to weather.” This is an observational study of 26,862 patients seen by members of the National Spine Network (NSN). The NSN is a group of spine centers throughout the United States. In this study, we used the results of the Short Form 36 (SF-36) in our analysis. The SF-36 measures functional status in 8 categories which include: General Health, Physical Function, Role-Physical, Bodily Pain, Mental Health, Social Function, Fatigue-Vitality, and Role-Emotional. “Barometric pressure consistently shows a strong negative relationship to all SF-36 subscales. Increased pressure was associated with worse outcomes.”

DISCUSSION Research findings “suggest that abnormal impulses generated at injured areas could contribute to increased pain and paresthesias and that these impulses are sensitive to and aggravated by cold temperature.” Research has shown that “pain behavior is related to decreasing of both temperature and barometric pressure.” Studies by Hollander provided evidence that weather does influence arthritic symptoms. Falling barometric pressure significantly affected symptoms. “These findings support common folklore.” [Hollander JL. Whether weather affects arthritis. J Rheumatol 1985;12:655-6]. One study noted that 76% to 83% of patients were able to predict rain by their rheumatoid symptoms. The study also showed positive pain correlations with barometric pressure in rheumatoid arthritis patients, osteoarthritic patients, and fibromyalgia patients. [Guedj D, Weinberger A. Effect of weather conditions on rheumatic patients. Ann Rheum Dis 1990;49:158-9]. One study noted that those patients with a higher level of self reported pain were more weather sensitive. [Gorin AA, Smyth JM, Weisberg JN, et al. Rheumatoid arthritis patients show weather sensitivity in daily life. Pain 1999;81:173-7]. One study showed that chronic low back pain was influenced by the weather. [Jamison RN, Anderson KO, Slater MA. Weather changes and pain: perceived influence of local climate on pain complaint in chronic pain patients. Pain 1995;61:309-15]. 3 In one study, 76% of patients reported that sudden weather changes influenced their chronic pain. [Shutty MS Jr, Cundiff G, DeGood DE. Pain complaint and the weather: weather sensitivity and symptom complaints in chronic pain patients. Pain 1992;49:199- 204]. This current study, like some of the other studies, found a “statistically significant correlation between barometric pressure and symptoms.” “The two climate-related categories that showed no statistically significant correlations with any of the SF-36 variables were rainfall and phase of the moon.” CONCLUSIONS “A clear relationship between weather variables, especially barometric pressure, and SF-36 outcome measures was seen if considered from a purely statistical outlook…”

KEY POINT FROM AUTHORS: Barometric pressure has a statistically significant effect on self-reported health status and pain.

SUMMARY:

1) Musculoskeletal pain is frequently sensitive to variations in climate.

2) Barometric pressure changes (indicative of impending storms), consistently shows a strong relationship to musculoskeletal pain syndromes, including chronic low back pain, osteoarthritis, rheumatoid arthritis, and fibromyalgia.

3) The percentage of those that can predict weather changes by their symptoms is as high as 83%.

4) Patients with a higher level of self-reported pain are more weather sensitive.

5) These findings support common folklore.