Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 34

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.

"Evaluations Blood Pressure, Pulse, Height & Weight"

Does this sound ridiculous to you? It does to me. Why should I take the vitals of a patient when all I am doing is adjusting them? The answer is simple…because it is an integral part of a basic evaluation. What if the patient has abnormally high blood pressure, tachycardia or is too short for their weight? This all needs to be documented. Furthermore, it is a reason for referral or to be monitored while caring for your patient. These are the very basics we were all taught in professional school and are performed by every health care professional in the nation during a basic examination. The implications of taking the vitals of your patients go well beyond the health of the patient, although that is the paramount reason.


As for coding and billing, there are a minimum number of parameters required in billing a 3, 4 or 5 level evaluation and over time, a certain number of items must be done. Vital statistics are part of that requirement, and when a carrier is looking at both reimbursement and compliance issues, those are a primary area of concern.


Secondly, when a lawyer looks at your report and “sizes you up” as an expert, they consider your examination a valid “yardstick.” You are being looked at as a spinal expert and are being compared to every other spinal expert in your community; the orthopedist, neurologist, neurosurgeon and physical medicine specialist. These medical specialists all have the vital statistics inherent within their reports and if you do not, a question will be raised with the lawyer that shouldn’t be raised. Why isn’t the examination complete? This can invalidate you as an expert in the mind of the potential referrer and cause them to bypass you in the referral process. Something as simple as weighing a patient can be the downfall of a healthy PI practice. Take the time for the right reasons…your patient.

PLEASE TAKE FURTHER NOTICE: CONFIDENTIALITY AND PROPRIETARY INFORMATION NOTICE:  This email including attachments is covered by the Electronic Communications Privacy Act (18 U.S.C. 2510-2521) and contains confidential information belonging to the sender.  Nothing contained in this message or in any attachment shall constitute an Electronic Signature or be given legal effect under 44 U.S.C. 3504 Sec. 1707.  The information is intended only for the use of the individual or entity to which it is addressed.  If the recipient of this message is not the intended recipient, you are at this moment notified that any unauthorized disclosure, dissemination, distribution or reproduction of this message or any attachments of this communications is strictly prohibited and may be unlawful.  If this communication has been received in error, please notify the sender immediately by return email, and delete or destroy this and all copies of this message and all attachments.