Academy of Chiropractic
Quickie Consult 1270
Narratives 100 N
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
Anatomy of Documentation
Avoiding a lawsuit
“See..Mirrors don't lie" Mark Studin 2020
A doctor sent me this and asked for a comment on his Macros. His Macros are in Black, and my comments are in RED.
FINAL CHART ENTRY
We have lost contact with Robert and cannot give an accurate accounting of his present health status.
Keep your comments in the affirmative, and do not give the perception that you are the cause for your patient's treatment non-compliance. Also, NEVER use a patient';s first name in a report, it renders the further perception of prejudice. Suggested language "Mr. Jones last visit was 08/12/2020 and at that time the findings revealed [....] These findings are consistent with his accident date 03/01/2020 and appear permanent based upon ligamentous failure evidenced by x-ray digitizing done on 03/15/2020, as supported by Lin et. Al. (2002).
See last Progress Note
FRAUD ALERT. On every visit, you must have a symptom, clinical finding and diagnosis for each area touched. This is non-negotiable and the "lazy-man's" shortcut will potentially get you very close with a criminal defense lawyer. IF... There is a pattern of your paperwork defrauding a financial institution in a systematic manner, this rises to the level of RICO under the Federal Racketeering Act, and then you get to pay for a criminal defense lawyer's beach house in the Hamptons.
(V49.49) Driver in a collison w/ other motor vehicles in traffic accident, (G44.311) G44.311 Acute post-traumatic headache, intractable, (M62.830) M62.830 Cervical Muscle Spasms, (M60.88) M60.88 Cervical Myositis, (M75.52) Bursitis of LT shoulder, (S43.402A) S43.402A Shoulder (L) Sprained Jnt unspec. init encntr, (M75.51) Bursitis of RT shoulder, (S43.401A) unspec. sprain of RT shoulder joint, (M62.830) M62.830 Thoracic Muscle spasms, (M60.88) M60.88 Thoracic Myositis, (M62.830) M62.830 Lumbar Muscle Spasms, (R25.) R25. Lumbar Cramp and spasm, (S33.5XXA) S33.5XXA Lumb Sprain * of ligments i, (S39.012A) S39.012A Low back Strain * of muscles, (S23.3XXA) S23.3XXA Thoracic Sprain of ligaments init enc, (M24.28) M24.28 Thoracic disorder of ligament vertebrae, (S13.4XXA) S13.4XXA * Cervical Sprain of ligaments, (S13.1XXA) S13.1XXA * Cerv STRAIN Mus Facia Tend
I previously sugggested that you stay within the 12 diagnosis allowed by the HCFA form, with some exceptions to go beyond. This doctor used 20, and they all appear to be legally defensible. This doctor did NOTHING WRONG. However, the carriers have made it clear they have little tolerance for this apparent "Colossus Busting" action. This type of recommendation was originated by vert smart consultants (not me), who figured out how to beat the system without regard for the legal backlash. I am much more conservative and compare what we do to neurosurgeons, orthopedic surgeons, and other medical specialists. This makes you an "outlier" and this action ALREADY has garnered significant attention in Federal RICO suits by too many carriers. Stay with 12, with more being the exception, not the rule.
The patient was not yet at Maximum Medical Improvement, or MMI. There was still room for therapeutic gain in functional improvement, reduction in symptoms and or reduction in interference and or loss of enjoyment of his past listed activities of daily living.
The patient was not yet at Maximum Medical Improvement, or MMI. There was still room for therapeutic gain in functional improvement and reduction in symptoms and or reduction in interference and or loss of enjoyment of his past listed activities of daily living. The last part is pandering to the plaintiff through utilizing specific Colossus language. It isn't necessary to add that for patient care, or prognosis. What it does, is put you on the "carrier's radar" for being an "outlier" and focusing on Colossus vs. patient care.
LOSS OF ENJOYMENT OF LIFE:
Mr. Smith continued to suffer from a direct loss of enjoyment of life due to this accident.
Loss of enjoyment of life equates to "that which can no longer be done after a reasonable course of care has concluded." What can no longer be done? I don't know because it is not detailed. This statement is useless.
EFFECT ON QUALITY OF LIFE
There had been a change in function and performance and is measured as very real substantive loss to this patient's quality of life.
This says absolutely nothing. First, this belongs under persistent functional losses, or loss of enjoyment of life. There must be specifics.
PATIENT SPECIFIC PROGNOSIS:
In my opinion Robert will also be left and have per-meant damage from the injury sustained. It is my opinion that he will be left with some ligamentous and muscular weakness in the areas of complaints that can be attributed directly to the injuries sustained in the accident of 7/8/2020 . He will likely all medical reasonable probability have additional pain in the future that is a result of the injuries which will require treatment as they arise. Medical research also indicates an individual who sustains a “ soft tissue trauma” injury to the spine is pre disposed to develop premature arthritis in the area of injury.
These are the only 2 prognosis that should be considered:
1. Undetermined, treatment indicated
2. Undetermined, treatment concluded, Static MMI
The patient will in reasonable medical probability require the following future care:
It either is, or isn't indicated. Remove the word "probably" in all report. Only report what "is," vs. what will probably be.