Academy of Chiropractic
Doctor’s PI Program
Quickie Consult 1075
Infrastructure 233 I
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
"Documenting Two Accidents and Apportioning Them"
Dr. Studin: what's the issue? Start from the beginning, please.
Guest Doctor: All right, so I've got a patient, motor vehicle accident, neck and back injury. She already had MRIs and she had a new accident.
Dr. Studin: How long between the two accidents?
Guest Doctor: About a month, a month and a half.
Dr. Studin: Okay, so it's relatively fresh. Okay, go ahead.
Guest Doctor: Yes.
Dr. Studin: So, it was cervical, you can't say neck and back. We got to be real doctors about this. Cervical or lumbar? or cervical and Thoracic or cervical and Lumbar? Cervical and lumbar on accident one. Now accident two comes along. And what happens?
Guest Doctor: Cervical is about the same. No big changes in exam or complaints or anything like that. And the low back is much worse. Lumbar is an aggravation.
M. Studin: Did you have MRIs from the first accident?
Guest Doctor: We do, yes.
Dr. Studin: Okay. So, what are your findings in the lumbar spine? Do you recall?
Guest Doctor: Lumbar spine. She's got some positive neurological and orthopedics.
Dr. Studin: I asked you about MRI, not Ortho and Neuro. MRI. I'm looking for demonstrable physical bodily injury.
Guest Doctor: Okay. Let me pop up really quick. Okay. She has on the Lumbar MRI, she's got an L23 disc bulge, so probably nothing for us. L342 millimeter broad-based, right foraminal disc herniation, contact on the L3 nerve root, L45 disc bulge with some specific atrophy. And then L512 millimeter central disc herniation. So, 3,4,5 and 1 will be…
Dr. Studin: Okay. Have you assisted attorney’s issues? Have you read the images or just read the report? If you looked at the evidence or just read the report?
Guest Doctor: I just read the report because I didn't order them, but definitely good to
Dr. Studin: Yeah, you have to get a copy of the desk. That's a must. Because you need to know if those two are herniations there have motive changes with them. Is there a high signal outside, is an old versus a newer herniation? Is there a spur associated with it? So those are the things that are going to be your determinant really. Is it causally related to accident one? Now in accident two, did you order an MRI?
Guest Doctor: Not yet.
Dr. Studin: How long ago was accident 2?
Guest Doctor: It was just last week, and I haven't actually done an eval with her.
Dr. Studin: Okay. So, this is the answer and the lawyer want you to keep the two accidents separate to make it easy for the lawyer to argue and get paid in two separate cases.
Guest Doctor: Pretty much.
Dr. Studin: Got it. Okay. So, here's the answer. If the cervical, there's no clinical changes, signs or symptoms, then there is no indication that there's anything more than even an exacerbation. Now you're in New Jersey and there is provision for compensation for exacerbations. Now, are you aware of the difference in exacerbation and aggravation? You know the difference, yes or no?
Guest Doctor: Yes.
Dr. Studin: Okay, so, so if you think there's an aggravation then you might want to consider ordering, you know, an MRI or an EMG or something. But if it's just an exacerbation documented as suction, you know, and you can keep treating it. But in New Jersey, you need a separate chart for exacerbation and then when they bring them back to that pre-accident injury, you go back to the first job.
Guest Doctor: a separate north for exacerbation or aggravation?
Dr. Studin: Yes, both actually, but I would have no problems. If you don't think there's any additional bodily injury, and there's not much difference in pain scales, etc, then you really don't need a second shot. Just there's nothing there to talk about however
If there are significant pain scales or clinical findings, then there is. Then when the lumbar spine, same thing. If there's not much difference in pain and clinical findings, then why do you need a separate chart for nothing happened from the second accident. If in fact, you have significant clinical signs and symptoms that change, then there's potentially an aggravation, the new bodily injury, new MRI and knew everything and now you could do whatever you need to do and the lawyer and has to understand that those are your rules and you know you have no problems doing it If there are additional bodily injuries, absolutely there's going to be a new chart. But if there's not then you know what's the purpose? You know, can't I know a lawyer?
Guest Doctor: No, I know all that. And what I normally would do is I would keep the same chart, but I would have them do a new case with the pip carrier because I can have no separate case.
Dr. Studin: No, no, you can treat… if there's new bottling injury from case 2 you have two charts, the cervical, then we'll be chart one from case one and the lumbar would be chart 2 from case 2. But I would not suggest you treat them on the same day. So, you would document cervical in chart one and you document lumbar in short too, if there's no new bodily injury on cervical and there is no bodily injury on Lumbar, then you need to separate charts. And you need to note in chart number two to the person just like, it's a fresh case. Was in a preexisting accident a month ago, had cervical and lumbar problems, cervical pretty much didn't change, but lumbar showed aggravation. There were new clinical findings. There's new positive from there. Patrick was saved, etc., etc., and a new MRI is ordered based upon that.
Guest Doctor: In the lumbar case number two, I would only reference the cervical spine in the beginning and say, let's say my initial eval and see this is being treated on the different case because there was no causality here.
Dr. Studin: No, You're using the wrong language when you say that there's no causality. There is no additional bodily injury. None, no exacerbation, no bodily injury. There is no change. But I'm reporting that the patient did have a preexisting problem in the cervical spine. There was also a preexisting problem in the lumbar spine. However, this was negative before. This is positive now, this was the pain scale before. This is the pain scale now, therefore MRI was ordered to notice any changes, so the patients are the same imaging center, so they get the same protocols and then you'll compare one to the other.
Guest Doctor: Okay. And in case number one, I would just say, you know, there's been an aggravation to the low back, and she will be continued to be treated on a different case.
Dr. Studin: Yeah, I would document them. I mean you want full transparency.
Guest Doctor: And in case number one, should I even mention low back findings, lumbar findings, spasm, you know, MRI findings for the second one.
Dr. Studin: No….
Guest Doctor: But so, I wouldn't even reference the lumbar spine in case one… in my note…
Dr. Studin: In the lumbar spine, you would say lumbar was being treated in case one. However, the patient had a subsequent car accident and that treatment is going over now to a different case because the patient had an aggravation of his preexisting problem and then some point in time, again, after portion not yet…
Guest Doctor: So, what I do 2 finals then or one kind with the portion then…
Dr. Studin: Ask the lawyer. First, you want to see what you have, you might have nothing, or you might have everything.
Guest Doctor: Okay, Gotcha.
Dr. Studin: It's pretty straightforward.
Guest Doctor: And in regard to the PIP carrier, I'm not putting myself as a red flag by actually treating the same patient six days a week, three days a week for one case, three days a week for the other.
Dr. Studin: No, not at all. As long as you outline it clearly.
Guest Doctor: So, she would come in three days for the neck, cervical spine, three days for the lumbar spine up. Because I've had this happen before. And the carriers, what they do is they forced me to close the first case regardless of…
Dr. Studin: Nope, they don't force you. They want you. There's no forcing here. Make sure you have liens signed in the rock to the lawyers. Okay?
Guest Doctor: Okay. I'll do that. Awesome. Thanks, Mark.
Dr. Studin: Later alligator. Bye.