When Treatment Doesn’t Follow the Textbook
DOCUMENTATION
Kathy Mills Chang
Every doctor knows that no two patients are alike and that a true “textbook” presentation of a condition is rare. However, auditors and other third-party readers may not automatically understand that and may assume that your diagnosis is for a condition presenting by the “book,” including symptoms, complications, and response to stimuli that are somehow standard from patient to patient.
Allowing this misconception to stand means that you risk requests for additional notes (i.e., why won’t this patient’s condition resolve in the eight to 10 visits the book says it should?) and even outright denials. That’s perfectly understandable. If the patient’s health record doesn’t outline the various comorbidities and prognostic factors present that affect the need for and length of care, how can we blame third-party payer for their denials?
That means that you, the doctor, must explain, in writing, how and why each of your patient’s variables (also called comorbidities or prognostic factors) affect diagnosis, treatment, and the time it takes for the patient to return to health. In other words, your documentation should include each of the patient’s comorbidities and other factors that make them different from what a third-party reader considers “normal.”
If you overlook this crucial step, you’re doing a disservice to your practice and your patient. For example, a patient is treated for 18 visits using a variety of treatment modalities, including adjustments, passive and active therapies, examination and reexamination for the condition, and diagnostic radiology testing during the course of treatment. The patient’s condition is resolved after care. If the treatment screens and algorithms in the carrier’s medical review policy dictate that the condition reported should be resolved in eight to 10 visits, claims may be denied for any additional visits up to 18, or auditors may ask for notes to justify this extended treatment. This is a colossal waste of time, which delays when patients will receive the care they need.
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) has outlined comorbidities that affect treatment or alter “textbook” presentation of a diagnosis. Following are examples of comorbidities that the CCGPP has directly stated can affect chiropractic treatment. We’ve also added descriptions of how these may present in practice. When doctors use similar language in the assessment section of the documentation, the auditors are able to put down their “textbook” and understand
If you overlook this crucial
step, you’re doing a disservice to your practice and your patient. "
that the patient isn’t an example from a book, but rather a living being in need of medically necessary care.
Complicating Factors in Chiropractic Treatment
Patient characteristics
• Older age - Slower healing, possible mobility challenges, likelihood of other comorbidities increase.
• Psychosocial factors - Emotional state affecting treatment effectiveness or compliance with treatment plan.
• Delay treatment for more than seven days - Conditions get worse or complicated if the patient waits for treatment.
• Noncompliance - History of missed appointments and/or not following ordered treatment may slow “textbook” progress of treatment.
• Lifestyle habits - Smoking, alcohol use, and carbonated beverage consumption drastically decrease innate healing abilities. The same is true of poor sleep habits. If the body does not reach REM (rapid eye movement) during sleep or the cycle is interrupted by symptoms, the body will not repair properly or quickly.
• Obesity - Increased weight has been proven through research to complicate low back pain.* Extra weight around the anterior abdomen causes an increase to the lumbar lordosis, which causes altered nerve flow.
• Type of work activities - If the patient is continually being reinjured on the job, progress will be slow and/or overall treatment goals may have to be truncated.
Injury Characteristics
• Severe initial injury - A patient with a cervical fracture will likely have a much different treatment time and ability to follow normally prescribed treatments than one who “slept wrong” and is having mild, stiff cervicalgia.
• Severe signs and symptoms - Sciatica that presents on both sides can cause more mobility problems that result in joints becoming more fixed and muscles that may start to atrophy because of compensatory patterns. If the patient is having additional problems that involve numbness in the groin or anus, the patient may need comanagement with a neurosurgeon. Some chiropractors may say that high-severity situations ai e beyond the scope of chiropractic. This may be true, but the documentation of the patient in the assessment may be the difference between winning or losing a malpractice lawsuit due to improperly managing the case and causing the patient irrevocable harm.
• Number/severity of previous exacerbations -Chronicity indicates a deeper cause than initial acute injury. During a previous episode, the patient may have healed improperly, causing underlying seal' tissue or adhesions that complicate traditional treatment effectiveness.
• Treatment withdrawal fails to sustain maximum therapeutic improvement - If the patient’s condition can’t be stabilized in order to be maintained, there’s likely something preventing further healing. The original diagnosis may have to be altered to explain the presentation of the injury.
History
• Preexisting pathology/surgery - If a patient has recently had a knee replacement, he or she is likely to have impaired gait and posture that will complicate the therapeutic process of spinal correction. Additionally, if the patient
has a vascular condition that affects the extremities, he or she will likely have slower response to treatments for radiculopathy because of the lack of proper blood flow to the affected peripheral nerves.
• History of prior treatment - If that patient has tried anti-inflammatories, steroid injections into the facet joints, had a course of physical therapy, and has been treated by another chiropractor for back pain, the patient is likely to heal much differently than someone with unremarkable low back pain.
• C ongenital anomalies - If the patient has a right lumbar sacralisation and is experiencing symptoms in the right sacroiliac joint, traditional diversified adjustments will likely not be as effective as with patients with normal joint function.
• Symptoms persist despite previous treatment - This means the patient’s condition requires more aggressive or different care than what was previously attempted. The patient will likely require modifications that other patients will not.
*The Association Between Obesity and Low Back Pain: A Meta Analysis Am. J. Epidemiol. (2010) 171 (2): 135-154
Kathy Mills Chang is a certified medical compliance specialist (MCSP) and certified chiropractic professional coder (CCPC). Since 1983, she has been providing chiropractors with reimbursement and compliance training, ach’ice, and tools to improve the financial performance of their practices. Kathy leads a team of 15 at KMC University and is known as one of our profession ’s foremost experts on Medicare. She or any of her team members can be reached at 855 832-6562 or infofiKMClJniversity.com.
