Academy of Chiropractic Personal Injury & Primary Spine Care Program

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From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: many of these issues are small, yet each issue is just that… an issue. If you take care of the small issues, then the larger issues often take care of themselves and you can focus on the larger issues… a larger, more profitable practice and more family time.

“Treatment on the First Day of Care”

Necessity and Documentation
“I took an oath to help”  Mark Studin 2017


Many carriers give you a hard time for treatment on the first day of care, both in the denial language and not paying you. Although you think they are wrong, asshole, greedy and more, you have to remember where they are coming from. 

You are stuck in an algorithm (the carrier’s computer program) that is often a “one-size fits all” paradigm. Would the surgeon operate on the same day as the initial evaluation, would the oncologist start chemotherapy on the same day as the initial evaluation… No and No!!! BUT… the chiropractor does. Therefore, the conclusion is; we are greedy and are simply out to “bilk” the carriers out of money!!! 

Just ask any carrier or IME that is hired by them to do their “bidding,” they will confirm that we are greedy (did I say “assholes?)

Part of the problem is YOU and your documentation. Do you write on the first SOAP Note that the reason treatment is being done on the same day as the E&M encounter is the patient is in significant pain? Do you comment on not waiting for imaging and treating and if so, why order imaging in the first place if you don’t need it to treat? Put yourself in the claim rep’s postion trying to make a determination if you should be paid. Yes, this is a medical determination and not to made by an unlicensed cliams rep, however… never lose sight of the fact that your goal with the carriers is to get paid from clinically necessary services and you DON’T WANT A FIGHT… you just WANT TO GET PAID!!!


First, in your E&M Initial report, never document treatment. There isn’t a “T” in that report indicating treatment for a reason (it isn’t EM&T) and treatment belongs on a separate SOAP note. That included x-rays because x-rays are treatment. The necessity for treatment goes in the E&M report inlcusive of x-rays. 

On the SOAP note, a separate record that should be done the same day as the E&M report for treatment, you could consider language in the Plan portion that says “Mrs. Jones was in significant pain today on her initial visit and treatment was rendered today based upon the clinical presentation (Subjective, Objective and Assessment) in the initial evaluation and management encounter.”
That is the only entry on the SOAP note I would consider documenting. 

IF… x-rays or other imaging was either performed or ordered outisde the office, I would condsider the following: 

“Mrs. Jones was in significant pain today upon her initial visit and palliative treatment was rendered today based upon the clinical presentation (Subjective, Objective and Assessment) in the initial evaluation and management encounter pending the results of (name the imaging modality)”  

IF… x-rays were performed inside the office the office on the initial visit, I would condsider the following after you wrote a necessity comment in the plan of the E&M report for the x-rays with a separate x-ray report (for the treatment of x-rays): “Mrs. Jones was in singificant pain today upon her initial visit and  treatment was rendered based upon the clinical presentation (Subjective, Objective and Assessment) in the initial evaluation and management encounter and the x-ray findings” 

Not getting paid is often your fault because you haven’t “laid out” your plan and rationale. Remember to keep it SHORT or it often WILL NOT GET READ.

The “other side of the coin” is that carriers are just overly aggressive in the greed department and won’t pay you no matter what you say. Therefore, you need to create the “ammunition” for when you go after them. Either way, in the end… you should get paid!



Adjunct Associate Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences

Academy of Chiropractic
US Chiropractic Directory
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