Academy of Chiropractic

Quickie Podcast 1230
Narratives 97 N

From the Desk of Dr. Mark Studin
Academy of Chiropractic

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

"Critical Narrative Changes"


Dr Studin: I am on with Dr. Michael Schoenfeld. so today we're going to talk about E&M versus narrative reports and why people are confused between the two, this program changes and today is about what changes and how you are in your business are reflecting the changes in our program because you only work exclusively for our clients because pretty much they're the only ones. They get it because you have been trained, And I could tell you that I've created relationships with the attorneys, they've increased their Rico division 400% and they're no longer going after like billing fraud and, they're looking at patterns on reports from reports or reports or report, and that's one of the prime things that they're going after in today's legal marketplace and in the educating the lawyer the first module in the CE course educated in the lawyer. We spend an hour and a half just about going through all of those pieces of minutia with the carriers going through. But really, what you're doing is you are reflecting those changes.

Guest Dr: Absolutely. 100%.

Dr Studin: So the first thing is we want to discuss the difference between E&M and narrative.

Guest Dr: Well, the bottom line is an E&M evaluation is just that an evaluation.

Dr Studin: Whats E&M stand for?

Guest Dr: evaluation and management and they're designed just to certify care for the insurance company. You're doing an exam, you want to bill it out to the insurance company and you want to comply with state laws and with federal requirements. So documentation, the big difference between that and a narrative, a final narrative is meant to report what conditions have persisted after a reasonable care and we're going to get into, well the things that go into a narrative that are not in a basic E&M report.

Dr Studin: One thing I want to discuss is it's not a final narrative, It's just a narrative. Can't use the word final because if a patient has the subsequent exacerbation and then you have to do another examination to see what's going on, then you're going to put an addendum on there. Then you just perjured yourself lie or made a mistake by using the word final and the report before. So you're not accounting for exacerbation. So it's your subsequent report, and what Dan Rosner, who teaches the testifying course with me, he calls it as four corners report, which is a legal word, meaning it covers the four corners of the case, which is synonymous with narrative reports.

Guest Dr: The wraparound report like Dan calls it four corners of a case report and it says just that it's taking everything that happened and That's going to be in your narrative that is not in your E&M report. So narratives include many things that are not in your report. All the doctors that your patients have seen, orthopedists, neurologists, physiatrist, they've had an EMG that have MRIs, they've had cat scans, they've had dental consultations with TMJ problems. Those are not in your E&M reports. They have to be in your narrative report. Also, the most important thing of narrative report to think about is you have to prove if this patient has a persistent functional loss and it usually can't be proven without a reasonable cost of care. So initially an E&M report sometimes is want to send their ENM reports to the lawyer. We cannot talk about persistent functional loss. It's a long-term prognosis You have to show, you have to show future treatment plans and also the estimated costs for your treatment going forward. Remember what I just said? It's for your treatment. Things in narratives shouldn't opine on what future care might be from an orthopedic surgeon or a neurosurgeon. Only stuff that you could say that you do that you think they might need. Also, many times, many of your patients that I've done thousands of reports, patients come in, they stopped coming in for some reason and an attorney wants a narrative report and of course your goal is to get that patient into your office to see how they are now versus how they were a year ago. And in our narrative reports, it's very important to define what these gaps in care are. When an attorney asks for an aggregate report, you stayed to the patient. Do me a favor. No, we're going to have about a four or five- or six-weeks gap in care, this depends on the case and I want you to not to come in here. I want you to do your exercises at home and when you come back and four weeks, we will evaluate you. Accurate exam of how you're feeling without care and doing all those things that you're supposed to be doing. Work sports, whatever you normally do, and that's very important because think about it, if you are treating the patients three days a week and you examine them, they might be feeling pretty good if you're a decent chiropractor, right? However, if they don't come in for four weeks and they do everything they're supposed to do, there's a good chance that their real true self will show through. So that's easy to do. Many of you are aware We are doing it. You think the patient's not going to come back for their evaluation? Trust me, they will. Because without that evaluation there's no report.

Dr Studin: But here's the other thing. You don't want them to have a gap in care. They're actually under active treatment. You have to understand the difference between active and passive treatment, active is what the patient does for themselves. Walking, bed rest, getting massages, stretching. That's active care. passive care is what a doctor does to a patient. Adjustments, heat. Injections, surgery. Those are all points of passive care. And our little myopic world of chiropractic, we always thought that active care was adjusting and pastoral care was therapies. No, that's not the true definition of both, and I like to go three to four weeks. I found four to six weeks not necessary, the feedback that I've gotten from the community at large is three to four weeks. We'll show those losses coming at range of motions, decreasing orthopedic test popping up positive because the patients are now stressing a joint where the connective tissue, which is ligament, remember connective tissue pathology. And if you haven't taken the course, connective tissue pathology as spinal trauma pathology, you must, when collagen and elastin are replaced only with collagen and the joint diseases and it adhesives in the elongated position, the joints can have abberant function, abberant excursion. It's not going to move properly. It's going to get irritated. It's going to inflame, it's going to release cytokines, which is going to feed the brain and tell us it hurts. So these are all the things you need to learn. There's going to be that negative neurological cascade that you need to learn about that we do in the primary spikier courses that you could see how all the courses start to be intertwined. So when you have that ordered gap in care and you need to explain this to a lawyer at some point in time, but you're patient, But you need to understand that almost at the cellular level which we teach you, but that ordered gap of care from a colloquial explanation is stress in the joint. And when you do that, it's going to get irritated. When you do that, it's going to move less. It's going to cause pain, positive orthopedic tests. You want to see what has persistent after a reasonable course of care is concluded or even after a reasonable course of care, you might want to re-institute that care and not an EM either, you've got to look at that joint, but it's not a gap in care. It's an ordered active care period, it's part of your treatment plan, but you have to ensure that the patient come in every 30 days for reevaluation under ongoing rehabilitation and active treatment as part of ongoing rehabilitation and part of that 30 day rehabilitation or re-evaluation cycle.

Guest Dr: Correct. Now that gap in care is also very important for you Marketing to attorneys. Very few chiropractors outside of Mox program. Probably follow that course of care. You're going to show the attorneys why you are different, special and you know exactly what you're doing, and that's very impressive. I've spoken to attorneys and they've never heard of it, remember what this whole program is about Differentiating E&M from narratives. I think about it at the end of care Perhaps you might be doing a digitalization of your XRAYs. And if do that in the beginning, you might have to do it again. You should be doing it at the end to compare. See if ligament laxity is persistent. That could only go in your narrative report.

Dr Studin: in order to determine and then you cannot certify in a report that ligament laxity is persistent, from an impairment perspective because that only occurs at MMI. Originally it helps guide your cat. It helps you develop a home exercise program and adjusting protocol and exercise program on your office, ultrasound, whenever you want to do. Exercise, rehab, wobble board, It's however you best treat your patient. You have to make that clinical decision. However, all that matters is that MMI for impairment. And by the way, we just released this week, a company called Symverta It is the only x-ray digitization program that pro rates impairments based upon the literature. It's all literature based and it goes well beyond just the AMA guides. So what we're looking for is we're going into that connective tissue pathology course, spinal trauma pathology, or delving into those things which would create in its join and allow us to determine a pro-rata impairment based upon not meeting the full threshold for AOMSI And remember, AOMSI is only for impairment rating. Laxity of ligament is about tissue pathology. Two separate things that happened to intersect that some point, but there are two individual scenarios. I'm more concerned about laxity of ligament, an impairment rating because the lacks of the of ligament is about tissue pathology and what's going on with the patients for the rest of their life. And I'll also be able to prognosticate what will go on with them and wrong with them and happen 10, 20 years from now and give them the treatment plan that'll last the rest of their life in the form of active care versus AOMSI is just about certifying impairment, but this legal case.

Guest Dr: briefly we're going to go through things maybe five things really quickly now that should be in your narrative report and that are not in your E&M report results of an epidural steroid injections, radio frequency, ablation surgery the patient might've had. You're going to have your emergency department and your urgent care records that you're going to review. You can have the total number of chiropractic plus physical therapy, massage or acupuncture visits. You're going to discuss devices and supports given to the patients tens units, braces, colors. And then finally we're going to discuss final functional losses including duties under duress and functional losses and losses of enjoyment written in the patient's own words. No check off sheets if you want to be Colossus compliant, right?

Dr Studin: The answer is yes. the patient's own words in paragraph format. You've got to be careful about the words Colossus compliant. And again, if this goes to my relationship with the the insurance companies and also reading some of the Rico complaints against our doctors and right now, and it's 2020, I have four doctors that I'm working with that are defending themselves in Rico allegations and two of them specifically, I read the issue on from the carriers and I've spoken to their attorneys, they're looking at patterns of your reports and there are certain reports that look exactly like it's a Colossus busting program for that purpose. So you've got to keep your report old fashioned, try to improve it, current history, past medical history, etc. But when you get it, the functional losses, it's okay to describe all of those things. But when you have listing after listing 30, 40 pages of items that looks like it's all designed to bus those things, you might be put in the crosshairs but in paragraph format, if you put that information as Michael just said, duties under duress, which I could still do, but to a lesser degree due to pain and you could list those things out You have no issue if you want to put prognosis, provide report, that's perfectly fine, if you want to put what I can no longer do after reasonable course of care is concluded that's listed out and you want to talk about inside the house, domestic, outside the house, such as painting the lawn, mowing, weaving, etc, That's all under that category, next is number four: work. And the last one is academics. When I could no longer do, for instance, I have to carry a backpack or a suitcase on wheels cause I can't carry my books or have to sit in the back of the room because I have to stand every 10 minutes. I can't focus on studying because of the pain in my neck is persistent. So if you want to break all of those things down into categories, that's great. Paragraph format and it works.

Guest Dr: can you think final impairment or current impairment ratings belong in the report?

Dr Studin: the answer is unequivocally yes, only final, all that matters. You cannot have an impairment rating unless you've MMI the patient. Those are the rules.

Guest Dr: So impairment ratings go in your narrative. Do not go on your E&M reports. And finally, the most important paragraph or paragraphs in your narrative is what Mark came up with. Pulls it demonstrative evidence and conclusions. It ties everything together. It ties your orthopedic findings, neurological findings, your MRI, any of your objective findings together in one cohesive, coherent paragraph that puts the whole case together. What happened to the patient? What did it do to the patient? Why is the patient going to have a problem perhaps for the rest of the life? That's called the mustard of evidencing inclusion.

Dr Studin: And you're tying together three things, causality, the bodily injury and persistent functional loss. You're tying those three things in your conclusion and there are four words that it has to start with from here forward, but for this accident. And those legal triggers, those words. And that was something Dan Rosner taught me recently. Watch for this accident. Mr. Jones, would not have had these injuries. And then the conclusion always has to start with, but for this accident. And it's really important to do that, to be able to get that in. Now I want to talk just briefly about static versus stable because people are still confused.

Guest Dr: All the reports that I do, I would say 99% of the reports they do of course are written at MMI. That's usually when a narrative is done, at MMI You're saying the patient has reached a point where their maximally medically improved, so treatment that you're going to give them after that is not going to improve them. It's hopefully going to keep them feeling well that is defined as static. Static MMI is when the patient comes to you periodically for one adjustment to keep them exactly where they are and hopefully not going backwards. There's probably no chance as you're going to have improving. stable, which is very rarely used maybe once a year I use it is if a patient is still coming to you for specific body part and you're treating that body part with the hopes of getting it better. However static is 99% of the time Correct. If you guys are writing stable, you going to have to talk to Mark or to me about the definitions.

Dr Studin: I'll just going to clarify one thing. If a patient comes to you periodically, it's not to keep them well that's maintenance and maintenance has no purpose in the healthcare insurance, medical, legal world because you have connective tissue pathology, a strange sprayed, primary, secondary, tertiary, you're stressing the joint. When you go through your normal activities of daily living, when you stress the joint, you're going to slide backwards just a hair from where you were at an MMI, the purpose of that ongoing care is bring them back to that point of MMI so they don't slide way back and now the joint further degenerates or advances that degeneration or accelerates it. So you're not keeping them at that MMI point, they're not staying at that end of MMI point. Once they go back into their repetitive lifestyle, they're going to be slipping backwards a little bit and your periodic cares to bring them to best back to the line of them MMI and that's what your care does. and you have to explain that to the patients so that they don't get frustrated. when collagen ended, they lasted, replaced all their with collagen and it's permanent and will never go away. That's exactly what's happening inside your connective tissue. So what's happening as a result of that, when you have that gristle connecting the joint, that joints not going to move normal. It's going to move accurately and it's going to persist the lifetime of your patient. So you have to let them know that the joint can't be held in a normal juxtaposition with respect to the one above the one below in that particular joint, and it's going to inflamed. It's going to irritate you, it's going to fall backwards. And then your treatments, bringing them back to where they were because the best they're going to be ever is the last day of your regular ongoing care. After that, your job is to be slipping and checking back and forth, back and forth to bring them to that line.

Guest Dr: Throughout most of the stuff, the bottom line is you can see a narrative is a wraparound report. Just like Dan says, it covers the four corners of the case and is your summation of what happened and how it will affect the patient for the rest of their life. And an E&M report and evaluation and management report is just a snapshot in time. It's how they were on one day for one hour when you evaluated them. It does not replace a properly organized narrative report.

Dr Studin: there's two items I want to finish up on. Number one, in E&M, you have to understand that it's not how much time you spend with the patient. It's done on a bullet system. And there's a five level report. It's a 16 bullets, four level report, 14 bullets, etc. And that's been around for a long time. But I think that came out in Medicare, I don't remember the feds came out with that initially. I believe it was in 1997 is when they came out with that, it's still viable. The second thing is, is I urge all of you and most of our more successful offices use Dr Shoenfeld's report writing service. And he's number 18 on the homepage of the consulting site at lawyers, and they all point to the same place. They all point the lawyer' and just go to the homepage, scroll all the way to the bottom. You could find Michael how to reach them, how to call him, what to send when he needs. But the cool part about it and the most important thing is that he does oversight. If you miss something, he's going to bounce it back and say, Hey, I need this. I need this because you don't want to piss off the lawyer. You need this in your report. And the other thing is everyone I speak to, Oh my God, I got four or five reports on my desk. I got to get out. You got to get to it. You're busy. You're really pissing off the lawyer. Why? By not getting it to them, not timely, which is two, three, four weeks, but quickly, because lawyers have something called DED, Discovery and deadlines and lawyers have known about it for six months, but almost every lawyer wakes up because they don't focus on it. Their staff does it. And then they're two, three weeks out and they need your report. Like yesterday, some warriors don't do it for a week out. They need a today. So if you wait two or three weeks to get them a report, or even the longer they're going to be angry with you, which is their fault, but they're still going to blame you. and if you need a report, in a day or two or three, you can call Michael and say, Hey, this one's 911 don't do that to Everyone or else I will be buried. If I was practicing today and I had Michael available to me, I would have him do every single report. So I have a homogenized product on every single report. And I know that Michael's reports reflect the latest of what's needed now to just to underscore that. Dan Roger and I, we're actually in the middle of recording the course called educated in the lawyer. You're not going to be able to get it for about three or four months while we go through the CE process. Michael is already starting to listen to them and making the changes in those reports. So he is way ahead of you. So these are the things you need to avail yourself. It's the cost of doing business and it is $150, takes about three to four hours for him to do a report. Four to six hours for you to do a report. So are you worth more than 30 bucks an hour? That's what it comes down to. Every one's worth more than 30 bucks an hour. And if you think your secretarial staff has the ability to do it, you're clueless. Michael, is there anything else we need to add?

Guest Dr: No. I mean, the only thing I wanted to add is the fact that a good narrative is going to be your window, your tool to get into an attorney's office, these are these narratives that you do, but might not be as good as the ones that we do. And it'll open up a floodgate of new patients for you Hopefully

Dr Studin: one word reputation. And you don't get a whole lot of chances. You only get one chance at a first impression for your reputation. But how many more chances that you get until it's destroyed? And you'll never know why that lawyer stuff's working with you again. And variably I can tell you it's always about your documentation. Michael, what's your, what's your phone number?

Guest Dr: (516) 695-7732 .

Dr Studin: And go to the homepage. Number 18, scroll to the bottom.

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