Academy of Chiropractic’s Lawyers PI Program

Narrative #9

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

“Reporting Treatment in Conjunction with Diagnosis”

With a commentary on initial and final prognosis
 
Disclaimer: Colossus is a registered trademark of Computer Science Corporation and is used here for purpose of identification, description of comment. It is also used as the generic name for the myriad of programs used by various carriers.

Source: Much of this information was obtained and shared with permission from James Mathis, former State Farm and Allstate representative. 

When reporting treatment in a narrative it is critical to understand this is not a letter of necessity seeking more care. It is to report what has transpired throughout the course of care. Treatment is also to be reported in concert with your diagnosis.

It is critical to include the number of visits and the range of care, noting the beginning and end of care per diagnosis. You must also include the provider of the care by name. The longer duration of chiropractic care, the lower the value of the case unless the visits are sandwiched between medical provider visits. 

In reality, after caring for trauma patients for decades, this algorithm is consistent with the severity of the patients I have care for.  I cannot recall treating a patient with serious injuries unless they had been co-treated by a medical specialist. Again, this is another area that I agree with the carriers. 

Unlike other body parts, spinal care must include the specific treatment dates. Therefore, it is imperative to attach all SOAP notes. I urge you to ensure I have reviewed your SOAP notes for both accuracy and compliance. It is far better for me to critique them for compliance than the carriers. 

Should the chiropractic visits be sandwiched between medical specialist’s visits, than the weight of the chiropractor’s treatment increases. Sandwiching chiropractic care with medical specialist’s evaluation has multiple benefits to the Colossus Algorithms. Upon your initial, or re-evaluation a prognosis must be documented. The following are the different prognosis indicators accepted by Colossus:

A - Undetermined
B - No treatment recommended/ no complaints                
C - Complaints/ no treatment recommended              
D - Complaints/ treatment recommended                   
E – Guarded

A-B-C within Colossus are reserved for chiropractic care. The reasons are an excellent business move on the part of the carriers (read the introduction to fully understand why). Each value has an increased value from lowest to highest. Chiropractors are allowed to utilize D if concurrently documented by a medical specialist. This is another reason that referrals are critical for Colossus, but only if clinically indicated.

Treatment duration is dependent upon a multitude of factors, but the patient’s symptomatology should be diminishing over time. The purpose of duration is that it reflects the impact the symptoms have to the patient over time. Duration is dependent upon both severity of symptoms in conjunction with the diagnosis with a focus not solely on spine as that is both potentially inaccurate and diminishes the value drivers. Reporting all diagnosis, not just which is allowed on a single HCFA form is critical and a supplemental HCFA form should be utilized (explained in a different consultation). 

When considering duration, documenting severity of symptoms is covered in the Consultation (currently Narrative #52) titled: Reporting Pain: Visual/Verbal Analog Scales. Please refer to this section on how to do it accurately and compliantly. 

Medication must be documented in the narrative.  Duration is determined to be either short term or long term.  Short term is less than 30 days.  As expected long term has a greater effect on value than short term.

Injections must be described as to type and number in the chart notes.  The number and type have an effect on value.

Physical therapy and massage therapy are reported differently from medicine and chiropractic when discussing duration of care. The indicators for duration of treatment for these providers are as follows:

§     Short less than 90 days
§     Short Intensive less than 90 days and more than 2 times/week
§     Prolonged longer than 90 days
§     Prolonged Intensive longer than 90 days and more than 2 times/week

Each of these indicators has an increasing weight in determining the value of the claim. The same indicators for duration are used in describing home exercise programs and other home care.  Therefore, it’s very important to document the period of time which the patient/claimant is performing home exercises. 

Home traction must be documented in the chart notes that it is prescribed and the duration required.  

Prescription or use of a Tens unit must be documented in the chart notes.  It can be at home or provided in office.   The duration must be documented in the charts.  

Immobilization must be documented in the records as well as the type.  Whether it is a collar or lumbar support, each has a direct weighted impact on value.  Duration is also important to value and must be documented in the charts.

Confined to bed must be documented in the records as well as the duration.  This has a substantial effect on the value of the claim.

Reporting treatment is handled diagnosis-by-diagnosis and includes associated symptomatology. The following are examples of reporting requirements that would best be accepted by Colossus. These formats are consistent with every other type of reporting requirements that would be accepted by academia, courts and/or licensure boards because it is factual. 

Sample treatment section:

SPINAL INJURY

Diagnosis

953.0 Injury to Cervical Nerve 

Provider                               # of Treatments         Last treatment date  

Mark Studin DC                     36                                7/14/2014
John Smith MD, PMR             3                                 7/16/2014

Provider                                                     Initial Prognosis

Mark Studin DC                       Complaints/treatment recommended
John Smith MD, PMR              Complaints/treatment recommended

Provider                                                  Final Prognosis

Mark Studin DC                      MMI (maximum medical improvement) Static
John Smith MD, PMR             MMI (maximum medical improvement) Static

Persistent Complaints:

Symptom                                       Doctor                             Date Reported

Loss of range of motion        Mark Studin DC                     7/14/2014
Cervical spasms                     Mark Studin DC                     7/14/2014
Cervical pain                          Mark Studin DC                     7/14/2014
Headaches                             Mark Studin DC                     7/14/2014
Pain radiating into left arm  Mark Studin DC                     7/14/2014
Sleep disturbance                  Mark Studin DC                     7/14/2014
Ringing in ears                       Mark Studin DC                     7/14/2014
Difficulty driving                    Mark Studin DC                     7/14/2014


Associated Therapies

Therapy                      Duration                     Provider                     Last Therapy

Massage Therapy       Short-Term                 Main Street Spa         2/01/2014
Home Exercise            Prolonged Regular    Mark Studin DC         7/14/2014
Bed Rest                     Prolonged Regular    Mark Studin DC         7/14/2014
Home Traction           Prolonged Regular    Mark Studin DC         7/14/2014


Tests Required

Type                            Result                                            Ordering Doctor  Date

Cervical X-Rays          positive (see x-ray section)          Mark Studin DC  2/1/2014
Cervical MRI               positive (see MRI section)           Mark Studin DC  2/8/2014
Cervical Digitizing      positive (see digitizing section)    Mark Studin DC  2/5/2014
                                                                                                                     & 7/1/2014
Cervical EMG/NCV    positive (see EMG/NCV section) Mark Studin DC  3/5/2014



The same reporting has to be done per diagnosis of injury. Pain, dizziness, radiating, etc… are not injuries and do not need to be reported individually. Those are sequella to injuries. 

As a result of the reporting requirements, I would communicate with my medical specialists that I work with and request they include in their documentation the following parameters for a prognosis on EVERY visit: 

A - Undetermined
B - No treatment recommended/ no complaints                   
C - Complaints/ no treatment recommended              
D - Complaints/ treatment recommended                   
E – Guarded

…with the proviso that the last 2 will be the majority of recommendations.