MACROS

 Protect Yourself from the Carrier's "Fraud for Profit" Scheme

From the Desk of Dr. Mark Studin

 

 

Narratives #77

 

Over the last ten years, the carriers have been aggregating statistics and using appropriate practice patterns of individual doctors. Most of the claims in (Federal) court have been a reach. However, they have been successful in convincing the courts to move forward and destroying doctor's careers, and in turn, putting undue stress on families. 

These cases often drag on for 5-6 years, and the lawyers typically charge $200,000-$300,000 during that time to protect you. Most doctors settle and then have to pay large sums beyond the legal fees, and then the carriers add to the terms of the settlement that you will not bill them again; ever. Forever injuring your ability to earn a living.  

Unfortunately, I cannot erase your past. However, in a "going-forward" posture, I can help make you as bulletproof as possible. Also, most will not go through the legal angst in defending yourself, but one never knows. Therefore, you have to move forward in an affirmative posture, inclusive of adhering to the following HARD MARK RULE: 

For every diagnostic test and treatment ordered, you need a clinical reason documented in your notes as to why you ordered it. After the test results are had, you need a statement of how it changed your treatment plan or confirmed your diagnosis and current diagnosis.

Below is a ""living library" of macros to be used. Over time, I will be adding many more for you to use in your documentation to help make you bulletproof. These are NOT TO BE SHARED, they are copyrighted and for clients only. 

 

1. X-Rays explanation: In your initial evaluation, you need to have an order for x-rays, even if you take them yourself in your office. You must have an order for everything you do. I prefer to have the x-ray report on a separate document, however if you want to include it in your initial E&M, it is OK. 

 

Macros:

NOTE: RED WRITING ARE VARIABLES DEPENDING UPON YOUR CLINICAL DECISION MAKING

X-Ray Necessity

 

Based upon MR XXXXX's physical examination findings of muscle spasms, abnormal motion palpation, aberrant orthopedic/neurological findings, and visual decreased range of motion examination as outlined within the body of this report, I am ordering cervical [list views], thoracic [list views], lumbar spine [list views] to provide a detailed assessment of underlying spinal biomechanical pathology and concomitant tissue/osseous pathology. 

 

Initial Treatment

 

NOTE: Only list, as per the language below the initial treatments ordered. Remove the rest.  

 

Based on all the evidence, recommendations for initial care to include multimodal care inclusive of manipulation [chiropractic spinal adjustment], mobilization, ischemic pressure, clinic- and home-based exercise, supervised graded strengthening exercises, traction, education, low-power laser, massage, transcutaneous electrical nerve stimulation (TENS), pillows, pulsed electromagnetic therapy, or ultrasound – is indicated for patients with acute or chronic pain, where the origin of the pain is known or unknown, to improve pain and some ROM – in dosages and methods based on the practitioner's experience and the patient's specific situation.1

 

 1.Bussieres, A. E., Stewart, G., Al-Zoubi, F., Decina, P., Descarreaux, M., Hayden, J., ... & Srbely, J. (2016). The treatment of neck pain–associated disorders and whiplash-associated disorders: a clinical practice guideline. Journal of Manipulative and Physiological Therapeutics39(8), 523-564.

 

 MRI Orders

 

An MRI of the (cervical-thoracic-lumbar) spine is being ordered. The sequences ordered are listed below. The history and clinical presentation herein reveal a clinical dilemma as to whether there is a space-occupying lesion warranting surgical intervention. Based on the evidence, the patient's clinical findings, and the published research, the MRI is clinically and medically necessary.1,2,3  Pending the MRI results, the patient will be treated palliatively for pain management.

 

Cervical

T1 Sagittal 3mm

T2 Sagittal 2.5mm

T2 Axial or gradient 2.5mm

STIR sagittal 2.5 mm

No Gap

Clean through the disc

Up to Foramen on Sagittal

 

Thoracic

T1 Sagittal 3mm

T2 Sagittal 2.5mm

T2 Axial 2.5mm

STIR sagittal 2.5mm

No Gap

Clean through the disc

 

 

Lumbar

T1 Sagittal 3mm

T2 Sagittal 3mm

T2 Axial 3mm

STIR Axial 3mm

Stacking Axial view 3mm

No Gap

Clean through the disc

 

  1. Ryan D. Muchow, BS, Daniel K. Resnick, MD, Matthew P. Abdel, BS, Alejandro Munoz, PhD, and Paul A. Anderson, MD. Magnetic Resonance Imaging (MRI) in the Clearance of the Cervical Spine in Blunt Trauma: A Meta-Analysis. J Trauma. 2008;64:179 -189. 
  1. Boese, C. K., & Lechler, P. (2013). Spinal cord injury without radiologic abnormalities in adults: a systematic review. Journal of Trauma and Acute Care Surgery75(2), 320-330. 
  1. Ackland, H. M., Cameron, P. A., Varma, D. K., Fitt, G. J., Cooper, D. J., Wolfe, R., ... & Liew, S. M. (2011). Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results. Annals of emergency medicine58(6), 521-530.

 

Post-MRI Plan

 

You MUST document one of the 2 following scenarios in your SOAP Note subsequent to the MRI

 

Scenario #1: The MRI revealed a [herniated disc - tumor - etc.] and is being referred for a neurosurgical consultation. Further chiropractic intervention is pending the results of that consultation. 

 

Scenario #2: As a result of the MRI, no surgical consultation is necessary. However, the following is being ordered as a result of the MRI: 1) Continue with palliative care for pain management 2) chiropractic spinal adjustments to the (cervical-thoracic-lumbar) spine is being ordered. Based upon the MRI results, the technique is being altered by (minimal force – instrument adjusting – limited to xxx regions of the spine – etc.) The treatment plan will be altered based on the patient's response to care.

Reporting Pain Scales

 

NOTE #1: The goal of pain scales is to assign a number so that a doctor can understand your pain. Also, it gives cues as to the effectiveness of care, which should be reflective in the ongoing scale.  If you are showing a visual cue, then it is called the visual analog scale, if you are asking only, then it is called the verbal analog scale. It is my HARD recommendation to only use visual analog scales. Therefore, go tot he Internet and download the pictures of the "smiley faces" and post them on the walls of your examining room to refer to. 

NOTE #2:To further help understand the issue, the following is directly from a Federal Lawsuit initiated by Liberty Mutual:

The chiropractic defendants' predetermined course of treatment continued unchanged even when patients reported identical pain scores with no improvement over the course of multiple months.

For example, patient J.N. was first examined by Chiro on December 20, 2017, at which time he reported a pain score of 7 /10 and was prescribed an extensive course of treatment
including mechanical traction, therapeutic exercises, neuromuscular reeducation, and chiropractic manipulation treatment ("CMT"). After receiving this identical course of treatment three (3) times weekly for more than four (4) months, J.N. was evaluated again at Chiro on May 1, 2018 and stated that his pain had not improved and remained at an identical 7/10.

The chiropractic defendants' predetermined course of treatment continued unchanged even when patients reported identical pain scores with no improvement over the course of multiple months. For example, patient J.N.  was first examined by Chiro on December 20, 2017, at which time he reported a pain score of 7 /10 and was prescribed an extensive course of treatment including mechanical traction, therapeutic exercises, neuromuscular reeducation, and chiropractic manipulation  treatment ("CMT"). After receiving this identical course of treatment three (3) times weekly for more than four (4) months, J.N. was evaluated again at Chiro on May 1, 2018 and stated that his pain had not improved and remained at an identical 7/10.

NOTE #3: I suggest only rendering pain scales upon re-evaluations, as the number normally fluctuate from visit to visit. When reporting the pain scale on the re-evaluation, make sure to give a range accounting for that fluctuation and/or exacerbations. There also must be an independent number for each body region with bodily injury. 

Initial Evaluation MACRO:  Mrs. Jones complained of pain the (cervical-thoracic-lumbar) spine that was a 7-8 on a 0-10 visual analog scale. Her chronic pain is 7, with exacerbations to 8/10 with exertion.1

1st Follow-Up Evaluation MACRO: Mrs. Jones complained of pain the (cervical-thoracic-lumbar) spine that was a 5-7 on a 0-10 visual analog scale. Her chronic pain is 5 with exacerbations to 7/10 with exertion.1

OR

1st Follow-Up Evaluation MACRO: Mrs. Jones complained of pain the (cervical-thoracic-lumbar) spine that is still 7-8 on a 0-10 visual analog scale. Her chronic pain is 7, with exacerbations to 8/10 with exertion. This is indicative of a more serious underlying issue than previous considered as an initial conservative course of care has not changed her symptomotology. The plan is to change the treatment protocol to (technique changes to xxxx, referral to a surgeon, referral to another chiropractor, refer for MRI's, etc.). A further re-evaluation will now be performed in 2 weeks to determine the status of Mrs. Jones.1

This should be added to all scenario's above: The Visual Analogue Scale, the Verbal Rating Scale and the Numerical Rating Scale are valid, reliable and appropriate for use in clinical practice.1

1. Williamson, A., & Hoggart, B. (2005). Pain: a review of three commonly used pain rating scales. Journal of clinical nursing14(7), 798-804.

NOTE #4: Shortly, I will be sharing tools with you that take you away from the "symptom game" and be able to demonstratively show progression of spinal correction rendering necessity for long-term corrective care. 

 

S.O.A.P. Documentation: Treating Areas Beyond an Active Complaint - Eliciting Symptoms

As a full spine adjuster treating pathobiomechanics, It is common for a patient to complain of cervical and/or lumbar pain and not comment on the thoracic spine. We know there are patho-neuro-biomechanical (subluxations) lesions at the non-complained region based upon clinical evaluation. However, working in a medical model requires a symptom to complete the documentation requirements. Like it or not, you need to have a symptom for every region treated. Therefore, eliciting a symptom, when clinically present, is an acceptable academic standard for treating these regions.

S: Mrs. Jones, when palpating the thoracic spine, elicited a symptom in the mid-thoracic spine on the right of 2-3/10 on the visual analog scale

O: Myofascitis and muscle spasticity: T 6-9 on the right

A: M79.1 Myalgia Thoracic Spine

P: Thoracic Chiropractic Spinal Adjustment

 

Bone Scan

Mrs. Jones presented with (costosternal – sternoclavicular – etc.) pain. A clinical evaluation revealed significant tenderness in the region, and advanced imaging is required to conclusively diagnose the region to determine if a surgical, tumor or fracture management is required. A bone scan is being ordered due to the specificity of the test, and relatively low levels of radiation required.

 

Pain Management Referral 

Based upon the patient’s clinical presentation, an MRI of the (cervical-thoracic-lumbar regions) was ordered and performed. As a result of the imaging, there was not enough neuro-compressive findings to warrant an immediate neurosurgical consultation. Due to the persistent pain, a consultation is being ordered with an MD specializing in Pain Management. Necessary medical co-management will ensue and continue for the ordered time by the pain management specialist. Should the course of pain management fail, a neurosurgical consultation will ensue. 

  

Return to Work with /without Continued Care 

Return to Partial Work

[Mr./Ms. Jones] has progressed in care, and is able to return to work at [10-20-30%, etc.] capacity. [He-She] has not yet maximum medical improvement [MMI], therefore care will continue. The following restrictions apply: [no carrying beyond 10 lbs., no sitting for more than 30 minutes, no lifting more that 15 lbs, etc.]

Return to Full Work with More Treatment Required

[Mr./Ms. Jones] has progressed in care, and is able to return to work with no restrictions. [He-She] has not yet maximum medical improvement [MMI] biomechanically, therefore care will continue. MMI will be based upon subsequent re-evaluations and segmental function. 

Full Improvement No Additional Treatment Required

[Mr./Ms. Jones] has progressed in care, and is able to return to work with no restrictions. [He-She] has met maximum medical improvement [MMI] for passive [doctor's] care, with biomechanical residual tissue pathology. Therefore care will continue solely as a home exercise program, and must do so for a lifetime as there are permanent residual impairments. 


 The entire shoulder series is courtesy of Dr. Matt Erickson from Florida. Dr. Erickson is one of our Fellows and works extensively together with me on many projects as he is insightful, a brilliant writer and LOVES chiropractic. We all owe him a debt of gratitude for his continual "selfless" work. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. if you have any questions.  


Shoulder X-Ray

[Mr./Ms. Jones] reported the onset of acute [right / left] shoulder pain following a traumatic event. This correlates with my physical exam findings which demonstrates the presence of [acute shoulder pain, restricted motion, weakness, instability and loss of radial pulse] in the respective shoulder as outlined within the body of this report. 

According to Behrang et al., (2018), Radiography is indicated for traumatic shoulder pain or any etiology (p. S172).  Behrang et al., (2018) further reported, “Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex)” (p. S176).  Behrang et al., (2018) added, “Radiography is the preferred initial study performed in the setting of traumatic shoulder pain. It can delineate shoulder malalignment and most shoulder fractures [3,4]“ (p. S176). 

As such, radiographs of the patients [right / left] shoulder are indicated.  Therefore, I am ordering radiographs of the respective shoulder to evaluate for biomechanical pathology (malalignment) and fracture.  Pending the radiographic results, the patient will be treated palliatively for pain management. 

  1. Behrang Amini, MD, PhD, Nicholas M. Beckmann, MD, Francesca D. Beaman, MD, Daniel E. Wessell, MD, PhD, Stephanie A. Bernard, MD, R. Carter Cassidy, MD, Gregory J. Czuczman, MD, Jennifer L. Demertzis, MD, Bennett S. Greenspan, MD, MS, Bharti Khurana, MD, Kenneth S. Lee, MD, MBA, Leon Lenchik, MD, Kambiz Motamedi, MD, Akash Sharma, MD, MBA, Eric A. Walker, MD, MHA and Mark J. Kransdorf, MD. (2018).  ACR Appropriateness Criteria Shoulder Pain–Traumatic; Expert Panel on Musculoskeletal Imaging, Journal of the American College of Radiology, 15(5S), S171-S188.

 From Dr. Erickson: Below are 4 macros.  Two are for a shoulder MRI / MR Arthrogram following radiographs.  The other two are for a shoulder MRI / MR Arthrogram done immediately with radiographs.  When I spoke with my Harvard trained radiologist (she holds credentials in diagnostic radiology-I sat with her for my fellowship) and has over 40 years of experience, she basically said she would order an MRI over an arthrogram to start even though an arthrogram is a little better for partial rotator cuff tears and labral tears.  She said the arthrogram is more invasive and costly and in most cases the findings if present will show on the MRI.  She explained if it appears there is a tear in the cuff or labrum with the MRI and it is not definitive and arthrogram can be ordered.  She also said if the MRI is negative for a cuff or labral tear, but clinically it appears there is something going on, then one could order an arthrogram in that case as well.  Of course this is her opinion on the matter and other radiologists or specialists just go with an arthrogram if a cuff tear or labral tear is expected.   I personally prefer starting with a shoulder MRI after speaking with her being that it is less invasive and less costly and the other study can always be done later if needed.  Hope you like these.


 Shoulder MRI Following Radiographs Macro

[Mr./Ms. Jones] reported the onset of acute [right / left] shoulder pain following a traumatic event.  This correlates with my physical exam findings which demonstrates the presence of [acute shoulder pain, restricted motion, weakness, instability and loss of radial pulse] in the respective shoulder as outlined within the body of this report. 

According to Behrang et al., (2018), “Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex)” (p. S176).  

With respect to use of MRI for traumatic shoulder pain of any etiology, according to Behrang et al., (2018), “Noncontrast MRI has been shown to be effective in assessing bony morphology and bone loss in patients with traumatic shoulder injuries [13-17], and noncontrast MRI is effective in diagnosing most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries [16,18,19](p. S177). 

Considering the patient history of developing acute [right / left] shoulder pain following a traumatic event and my physical exam findings which demonstrates positive orthopedic/ neurological testing that is indicative of a traumatic soft tissue injury of the [rotator cuff, acromioclavicular ligament or labroligamentous complex] an MRI of the patients [right / left] shoulder is indicated. 

 Therefore, I am ordering an MRI of the respective shoulder to evaluate for a soft issue injury which may include but is not limited to the rotator cuff, acromioclavicular ligament or labroligamentous complex.  Pending the MRI results, the patient will be treated palliatively for pain management. 

  1. Behrang Amini, MD, PhD, Nicholas M. Beckmann, MD, Francesca D. Beaman, MD, Daniel E. Wessell, MD, PhD, Stephanie A. Bernard, MD, R. Carter Cassidy, MD, Gregory J. Czuczman, MD, Jennifer L. Demertzis, MD, Bennett S. Greenspan, MD, MS, Bharti Khurana, MD, Kenneth S. Lee, MD, MBA, Leon Lenchik, MD, Kambiz Motamedi, MD, Akash Sharma, MD, MBA, Eric A. Walker, MD, MHA and Mark J. Kransdorf, MD. (2018).  ACR Appropriateness Criteria Shoulder Pain–Traumatic; Expert Panel on Musculoskeletal Imaging, Journal of the American College of Radiology, 15(5S), S171-S188.  

Shoulder MR Arthrography Following Radiographs Macro

[Mr./Ms. Jones] reported the onset of acute [right / left] shoulder pain following a traumatic event.  This correlates with my physical exam findings which demonstrates the presence of [acute shoulder pain, restricted motion, weakness, instability and loss of radial pulse] in the respective shoulder as outlined within the body of this report. 

According to Behrang et al., (2018), “Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex)” (p. S176).  

Respectively, according to Behrang et al., (2018), MR arthrography is considered the gold standard for imaging traumatic shoulder pain [3,16,18,20]. MR arthrography is comparable with noncontrast MRI in the assessment of extra-articular soft tissues, and MR arthrography has been shown to be superior to noncontrast MRI in diagnosing intra-articular pathology such as SLAP tears, labroligamentous injuries, and partial rotator cuff tears [16,18] (S177). 

In addition, for traumatic shoulder pain, according to Behrang et al., (2018), an MR arthrography is the preferred examination for the evaluation if radiographs demonstrate a Bankart or Hill-Sachs Lesion (S180), if there is a history of a dislocation event or instability (S181), if physical examination findings consistent with a labral tear (S181) or a partial rotator cuff tear (S183).

 Moreover, with respect to shoulder MRI, Behrang et al., (2018) reported, “It has high sensitivity and specificity in detection of full-thickness rotator cuff tears, but lower sensitivity compared with MR arthrography for detection of partial-thickness tears [67] (S183).  Thus, if a rotator cuff tear is suspected, MR arthrography of the shoulder may be indicated over an MRI of the shoulder as it is more sensitive in detecting a partial-thickness rotator cuff tear. 

Considering the patient history of developing acute [right / left] shoulder pain following a traumatic event and [a reported dislocation or radiographically demonstrated Bankart or Hill-Sachs lesion] or [my physical exam findings which demonstrates positive orthopedic /neurological testing that is indicative of a traumatic soft tissue injury to the rotator cuff or labroligamentous complex] an MR Arthrogram of the patients [right / left] shoulder is indicated.

Therefore, I am ordering an MR Arthrogram of the respective shoulder [to further evaluate the reported dislocation event or radiographically demonstrated Bankart or Hill-Sachs lesion orto evaluate for a suspected rotator cuff tear and/or labral tear].  Pending the MR Arthrogram results, the patient will be treated palliatively for pain management. 

  1. Behrang Amini, MD, PhD, Nicholas M. Beckmann, MD, Francesca D. Beaman, MD, Daniel E. Wessell, MD, PhD, Stephanie A. Bernard, MD, R. Carter Cassidy, MD, Gregory J. Czuczman, MD, Jennifer L. Demertzis, MD, Bennett S. Greenspan, MD, MS, Bharti Khurana, MD, Kenneth S. Lee, MD, MBA, Leon Lenchik, MD, Kambiz Motamedi, MD, Akash Sharma, MD, MBA, Eric A. Walker, MD, MHA and Mark J. Kransdorf, MD. (2018).  ACR Appropriateness Criteria Shoulder Pain–Traumatic; Expert Panel on Musculoskeletal Imaging, Journal of the American College of Radiology, 15(5S), S171-S188. 

Immediate Shoulder MRI Macro

[Mr./Ms. Jones] reported the onset of acute [right / left] shoulder pain following a traumatic event.  This correlates with my physical exam findings which demonstrates the presence of [acute shoulder pain, restricted motion, weakness, instability and loss of radial pulse] in the respective shoulder as outlined within the body of this report. 

According to Behrang et al., (2018), “Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). (p. S176).  

With respect to use of MRI for traumatic shoulder pain of any etiology, according to Behrang et al., (2018), “Noncontrast MRI has been shown to be effective in assessing bony morphology and bone loss in patients with traumatic shoulder injuries [13-17], and noncontrast MRI is effective in diagnosing most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries [16,18,19]” (p. S177). 

While radiographs according to Behrang et al., (2018) are regarded as the preferred initial study for traumatic shoulder pain, radiographs are primarily used to evaluate for biomechanical pathology (malalignment) and fracture not soft tissue injuries (p. S176).  Considering the patient history of developing acute [right / left] shoulder pain following a traumatic event and my physical exam findings which demonstrates positive orthopedic/neurological testing that is indicative of a traumatic soft tissue injury of the [rotator cuff, acromioclavicular ligament or labroligamentous complex] an MRI of the [right / left] shoulder is indicated. 

As such, an MRI of the patients [right / left] shoulder is indicated.  Therefore, I am ordering an MRI of the respective shoulder to evaluate for a soft issue injury which may include but is not limited to the rotator cuff, acromioclavicular ligament or labroligamentous complex.  Pending the MRI results, the patient will be treated palliatively for pain management. 

  1. Behrang Amini, MD, PhD, Nicholas M. Beckmann, MD, Francesca D. Beaman, MD, Daniel E. Wessell, MD, PhD, Stephanie A. Bernard, MD, R. Carter Cassidy, MD, Gregory J. Czuczman, MD, Jennifer L. Demertzis, MD, Bennett S. Greenspan, MD, MS, Bharti Khurana, MD, Kenneth S. Lee, MD, MBA, Leon Lenchik, MD, Kambiz Motamedi, MD, Akash Sharma, MD, MBA, Eric A. Walker, MD, MHA and Mark J. Kransdorf, MD. (2018).  ACR Appropriateness Criteria Shoulder Pain–Traumatic; Expert Panel on Musculoskeletal Imaging, Journal of the American College of Radiology, 15(5S), S171-S188. 

Immediate Shoulder MR Arthrography Macro

[Mr./Ms. Jones] reported the onset of acute [right / left] shoulder pain following a traumatic event.  This correlates with my physical exam findings which demonstrates the presence of [acute shoulder pain, restricted motion, weakness, instability and loss of radial pulse] in the respective shoulder as outlined within the body of this report.  

According to Behrang et al., (2018), “Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex)” (p. S176).  

Respectively, according to Behrang et al., (2018), “MR arthrography is considered the gold standard for imaging traumatic shoulder pain [3,16,18,20]. MR arthrography is comparable with noncontrast MRI in the assessment of extra-articular soft tissues, and MR arthrography has been shown to be superior to noncontrast MRI in diagnosing intra-articular pathology such as SLAP tears, labroligamentous injuries, and partial rotator cuff tears [16,18]” (S177). 

In addition, for traumatic shoulder pain, according to Behrang et al., (2018), an MR arthrography is the preferred examination for the evaluation if radiographs demonstrate a Bankart or Hill-Sachs Lesion (S180), if there is a history of a dislocation event or instability (S181), if physical examination findings consistent with a labral tear (S181) or a partial rotator cuff tear (S183). 

Moreover, with respect to shoulder MRI, Behrang et al., (2018) reported, “It has high sensitivity and specificity in detection of full-thickness rotator cuff tears, but lower sensitivity compared with MR arthrography for detection of partial-thickness tears [67] (S183).  Thus, if a rotator cuff tear is suspected, MR arthrography of the shoulder may be indicated over an MRI of the shoulder as it is more sensitive in detecting a partial-thickness rotator cuff tear. 

Further, while radiographs according to Behrang et al., (2018) are regarded as the preferred initial study for traumatic shoulder pain, radiographs are primarily used to evaluate for biomechanical pathology (malalignment) and fracture not soft tissue injuries (p. S176).  

Considering the patient history of developing acute [right / left] shoulder pain following a traumatic event [and my physical exam findings which demonstrates positive orthopedic /neurological testing that is indicative of a traumatic soft tissue injury to the rotator cuff or labroligamentous complex] an MR Arthrogram of the patients [right / left] shoulder is indicated.  Therefore, I am ordering an MR Arthrogram of the respective shoulder to [evaluate for a suspected rotator cuff tear and/or labral tear].  Pending the MR Arthrogram results, the patient will be treated palliatively for pain management. 

  1. Behrang Amini, MD, PhD, Nicholas M. Beckmann, MD, Francesca D. Beaman, MD, Daniel E. Wessell, MD, PhD, Stephanie A. Bernard, MD, R. Carter Cassidy, MD, Gregory J. Czuczman, MD, Jennifer L. Demertzis, MD, Bennett S. Greenspan, MD, MS, Bharti Khurana, MD, Kenneth S. Lee, MD, MBA, Leon Lenchik, MD, Kambiz Motamedi, MD, Akash Sharma, MD, MBA, Eric A. Walker, MD, MHA and Mark J. Kransdorf, MD. (2018).  ACR Appropriateness Criteria Shoulder Pain–Traumatic; Expert Panel on Musculoskeletal Imaging, Journal of the American College of Radiology, 15(5S), S171-S188.

 PROGNOSIS

 This is one the carrier's got right, as this is a Colossus algorithmic phrase. We have no clue how the patient will react until MMI has been attained. 

"Undetermined - Treatment Indicated"

 

Once treatment has been concluded, if there are residuals, then it reads:

"Undetermined - Treatment Concluded"

 

Continued [Long-Term] Care

NOTE: This is where x-ray digitizing and the Symverta platform comes "front and center." This is one of the reasons we developed the platform. Determining AOMSI is a very small piece of the puzzle and why you need the ability to pro-rate impairments as that starts at pathology. It is that pathology that necessitates long-term care and gets you out of the "symptom-centered" approach of care, and into structural care. If you correct the underlying structural pathology, symptoms resolve.  

Continued passive [doctor delivered] care is clinically indicated. Our focus of care is to stabilize the pathobiomechanically injured motor units [spinal segments]. X-ray digitizing demonstrably shows connective tissue pathology[i] at [C5, C6, C7] and resultant biomechanical failure. Although these ligaments are permanently damaged,[ii] they need to be stabilized. Regional ranges of motion are unable to determine individual motor unit function, therefore repeat x-rays are ordered after 8 weeks of care to examine the individual motor units and determine if MMI has been attained. 

Since diagnostic x-rays have no adverse health effects as reported by Tubiana, Feinendegen, Yang, and Kaminski (2009), "Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv."[iii] They go on to state, "There are potent defenses against the carcinogenic effects of ionizing radiation. Their efficacy is much higher for low doses and dose rates; this is incompatible with the LNT (linear no-threshold) model but is consistent with current models of carcinogenesis. The ionizing radiation effects of taking a set of lumbar x-rays is well below the minimum dosage to have a carcinogenic effect." To summarize these and other authors, diagnostic x-rays have had virtually no negative adverse sequelae based upon this and the totality of other literature. 

The cost of an x-ray to diagnose segmental pathobiomechanical failure far outweighs the costs to treat the effects of Wolff’s Law [spinal degeneration]. This will help prevent the long-term symptoms related to advanced arthritis, which will occur over time should this pathology not be treated and then managed, if necessary. 

An interim evaluation will be performed in 4 weeks to assess treatment frequency and functional abilities.

 

[i] Lin, R. M., Tsai, K. H., Chu, L. P., & Chang, P. Q. (2001). Characteristics of sagittal vertebral alignment in flexion determined by dynamic radiographs of the cervical spine. Spine26(3), 256-261.

[ii] Hauser R., Dolan E., Phillips H., Newlin A., Moore R., Woldin B., Ligament & Healing Injuries: A Review of Current Clinical Diagnostics and Therapeutics,  The Open Rehabilitation Journal, 2013, 6, 1-20

[iii] Tubiana, M., Feinendegen, L. E., Yang, C., & Kaminski, J. M. (2009). The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology251(1), 13-22.

 Reporting Pain Between Evaluations

 

NOTE: It is suggested that reporting pain scales between re-evaluations be limited to "same, better or worse" than last visit. Most patient's pain patterns "ebb and flow" from day to day and an "lay-person" reading your S.O.A.P. note will not understand how the pain can be a 4 one day, and 7 the next visit, without the patient malingering. The reality is that patients, due to life's stressed will have pain that fluctuates in normal recovery. However, every 30 days should reveal an accurate trend in pain. It is also strongly suggested you use the Visual Analog Scale with all Pain reported. 

Macro: [Mrs. Jones] is reporting her pain today to be [slightly better] than her last visit. 

 

2-8 Week Gap in Care

 

NOTE: Unless, “as a matter of practice,” you add a home exercise program and lifestyle modifications with every patient, a gap in care of greater than 2-weeks cannot be overcome. First, a home exercise and lifestyle modification recommendation is in EVERY patient’s long-term interest with spinal related issues and SHOULD be ordered. Any Gap in care greater than 8 weeks needs to have a compelling answer to why with the Caveat that those are challenging to overcome in the insurance-medical-legal environment.  

Macro: [Mrs. Jones] has been in compliance with either at office or home care instructions. Her regimen of prescribed active care (self-performed) home exercises, loading (lifting) instructions, and lifestyle modifications, in conjunction with her passive care (doctor’s care) has helped her.   

 

EMG-NCV

NOTE: You must wait a minimum of 21 days (preferably 30 days post-trauma) for an accurate EMG test. Test results typically change how you triage the patient, not to localize care. The triage is HOW it changes your treatment plan, and must be documented. 

Macro for MOTOR LOSS: [Mrs. Jones] exhibits persistent motor weakness in the [name extremity or muscle] and an EMG-NCV is warranted as it is now [# of days post trauma] to determine if there is radiculopathy and/or neuropathy.  

Macro for Sensory Loss: [Mrs. Jones] exhibits persistent sensory deficit in the [name region or dermatome] and an EMG-NCV is warranted as it is now [# of days post trauma] to determine if there is radiculopathy and/or neuropathy.  

POST-TEST TREATMENT CHANGES

Macro for Positive EMG result for radiculopathy [no MRI done]: Based upon the the positive EMG result of [xxxx], an MRI is indicated to determine the etiology of the neurological lesion. This is a clinically indicated reason for an immediate MRI, and triage is pending MRI results. 

Macro for Positive EMG result for radiculopathy [if MRI was done previously]: The positive EMG result of [xxxx] matches the MRI findings of [xxxx], which confirmed the diagnosis.

Choice #1:Technique is being altered by (minimal force – instrument adjusting – limited to xxx regions of the spine – etc.) The treatment plan will be further be altered based on the patient's response to care.

Choice #2: A [Neurosurgical - Pain Management] consultation is being ordered. Further conservative care will be considered pending the results of the consultation. 

Macro for Positive NCV result for compressive neuropathy [carpal tunnel-cubital tunnel-tarsal tunnel]: A consultation with a neurologist is clinically indicated to determine the future course of care specific to the NCV result. 

Macro for Positive NCV result for neuropathy: A consultation with a neurologist or the patient's medical primary care provider is clinically indicated to determine the future course of care specific to the NCV result. 

 

Low Level Laser

 

[Mr/Ms _______] has been under conservative care for treatment of [his/her] [Shoulder-Neck-Low Back-Knee- etc.]  pain.   Although [Mr./Ms. _____] has responded to care, it has been slow in response and therefore I am ordering [8] sessions of Low Level Laser Treatment (LLLT) to help alleviate pain, swelling and inflammation and to facilitate healing.  

According to Roche et al., (2016) “Increasing evidence supports  the use of low-level laser therapy (LLLT) for treating several health conditions including wound healing, inflammation and edema, and painful conditions. Specifically, LLLT has been beneficial for treating pain associated with chronic joint disorders, musculoskeletal pain, and chronic low back pain” (pg. 98) 

LLLT is recommended for this patient because there is inflammatory tissue response as a result of this accident.  This will help prevent possible side effects of medications.  Berry, et al state “LLLT is being used to reduce pain, inflammation, edema, and enhance healing of various types of injuries.  The results of our work indicate LLLT is an effective treatment for low back pain and a safter alternative to opioids and nonsteroidal anti-inflammatory medications.” (pg. 4)

Injured areas of the body will have an inflammatory response that must be mitigated in order for healing to occur.  Huang et al., state “There have been a large number of both animal model and clinical studies that demonstrated highly beneficial LLLT effects on a variety of disease, injuries, and has been widely used in both chronic and acute conditions.  LLLT can also stimulate healing of deeper structures such as nerves, tendons, cartilage bones and even internal organs.   LLLT can reduce pain, inflammation and swelling caused by injuries, degenerative disease or autoimmune diseases.   LLT has been used to mitigate damage after strokes, after traumatic brain injury and after spinal cord injury.” (pg. 367)

  1. Roche, G. C., Murphy, D. J., Berry, T. S., & Shanks, S. (2016). Low-level laser therapy for the treatment of chronic neck and shoulder pain. Functional Neurology, Rehabilitation, and Ergonomics6(2), 97.
  2. Berry, T. S., Quarneri, P. J., Roche, G., & Sammons, T. M. (2020). Low-Lever Laser Therapy for Treating Low Back Pain: 12-Month Follow-Up. J Pain Relief9(347), 2.
  3. Huang, Y. Y., Chen, A. C. H., Carroll, J. D., & Hamblin, M. R. (2009). Biphasic dose response in low level light therapy. Dose-response7(4), dose-response.

 

X-Ray Digitizing [Symverta] Necessity 

 

[Mr/Ms _______]'s evaluation has revealed global ranges of motion (ROM) deficiencies in the [Cervical – Thoracic -Lumbar – Pelvic] region[s]. This, coupled with muscle spasticity in the [Cervical – Thoracic -Lumbar – Pelvic] region[s], necessitates the ordering of x-ray digitizing of the [Cervical – Thoracic -Lumbar – Pelvic] spine to determine "segmental" pathobiomechanics and rule-out global ROM compensation. This diagnosis is integral to the creation of an ongoing treatment plan and prognosis.   

 

Electroencephalogram [EEG] Necessity and Triage 

 

[Mr/Ms Patient]'s history and evaluation has revealed cognitive deficiencies (list: nausea, vomiting, disoriented, amnesia, irritability, lethargy, cognitive changes, vision blurred, altered breathing, loss of consciousness, headache, migraine, personality changes, ataxia, deviated gaze, ringing in ears, light sensitivity, balance), necessitates the ordering of an Electroencephalogram (EEG/qEEG) to determine the presence of an mTBI.(1, 2, 3, 4)   

1. O’Neil B, Prichep L, Naunheim R, Chabot R. Quantitative Brain Electrical Activity in the Initial Screening of Mild Traumatic Brain Injuries. Western Journal of Emergency Medicine. 2012; 13(5):394-400. 

2. Naunheim R, English J, Treaster M, Casner T, Chabot R. Use of Brain Electrical Activity to 72 Quantify TBI Brain Dysfunction in the ED. Brain Injury. 2010; 24(11):1324-1329.

3. Prichep LS, Ghosh-Dastidar S, Jacquin A, Koppes W, Miller J, Radman T, O’Neil B, Naunheim R, Huff JS. Classification Algorithms for the Identification of Structural Injury in TBI Using Brain Electrical Activity. Computers in Biology and Medicine. 2014; 53:125- 133.

4. Curley KC, O’Neil BJ, Naunheim R, Wright DW. Intracranial Pathology (CT+) in Emergency Department Patients With High GCS and High Standard Assessment of Concussion (SAC) Scores. Journal of Head Trauma Rehabilitation. 2018; 33(3):E61-E66. 

 

POSITIVE: Based on the positive qEEG results on [Date], a referral to a Neurologist is indicated to co-manage the patient, and determine the future course of care specific to the qEEG results.   

NEGATIVE: Based on the negative qEEG results on [Date], the patient will be palliatively treated for the symptoms they described during their first exam, if the symptoms persist a referral to a neurologist will be made to co-manage the patient.  

 

X-Ray Orders

 

 

 

 


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