Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 94

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.

"Diagnosis Update"


Do not be skimpy on rendering a diagnosis. Simply because the HCFA form limits you to 4 diagnoses does not mean you are limited to 4 diagnoses. You should diagnose every condition your patient has in order of importance and in order of relative weight (the topic of a previous consultation).

 

You should have a template of diagnoses with the relative weights attached. If you need one, it is available under forms and templates on the Web site. If the condition is due to an accident, you need to use an “E” code for causality. If you are using “Dorsopathy,” as outlined in consultation #85, you need to use the condition ICD and the Dorsopathy ICD. Although the HCFA maintains 4 codes, your report will have the rest of them and it is critical when treating your patients to use as many as necessary to accurately diagnose your patients. Here is an example of a complete diagnosis of one of my patients:

 

  1. 723.4 Cervical radiculopathy
  2. 723.0 Cervical spinal stenosis
  3. 722.0 C5-C6 disc herniations
  4. 732.3 Cervicobrachial Syndrome
  5. 722.10L3-L4, L5-S1 lumbar disc herniations with impingement of the left L5 nerve root
  6. 729.1Lumbosacral myofascitis
  7. 724.2Lumbosacral Syndrome
  8. 308.3Post Traumatic Stress Disorder
  9. 728.4Ligamentous laxity
  10. 781.2Gait Disorder
  11. 729.1Myofscitis

 

It is not uncommon to have 10-20 diagnoses based upon the patient’s condition. As a primary care provider, unlike the medical orthopedist or neurologist, you are caring for the whole body and not being consulted for one specific condition, necessitating a complete diagnostic conclusion. In addition, for compliance purposes, you MUST diagnose every area you touch with a corresponding positive clinical finding. These are non-negotiable issues.

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