PLAINTIFF REPORTS: at Boston Spine Clinics

It is crucial for the treating chiropractor to document his/her reports as fully as possible. For medical/legal reasons this has always been true. But in this age of managed care/cost containment, intense scrutiny of all doctors by insurance companies and their legion of IME subalterns, documentation of a case file has never been more important. Add to that, the utter carefree hubris of the insurance industry and their minions in filing complaints with Boards againts practitioners for a variety of issues, many of them trivial. This all means that the chiropractor in the new millenium now must be more exacting than ever before; with a newfound attention to detail not before seen in the profession. As I always say at my lectures, "Doctors, it is your case file that will either save you or sink you." To that end, I have introduced yet another main tab page on my WEB site to illustrate the continuing issue of chiropractor's reports. Remember doctors, you are the expert on a given case. For those of  you with extra credentials, all the better; serve you patients and your profession better by doing more detailed exams and subsequent reports.

Preponderance of evidence: Is a term used in law that is the equivalent of saying that the balance of evidence favors your position. In personal injury or any medical/legal forum, the defense (insurance companies usually) typically does not concern itself with preponderance of evidence. Instead, it (defense) attempts to simply confuse the tryer of fact which can be just a judge and/or a jury and make the plaintiff's case appear fragmented, uncertain, inconsistent, or most often, fraudulent. This is why, as a treating physician, it is necessary to provide unambiguous and probative testimony. The crucial way that the plaintiff can push the case favorably forward includes the detailed documentation of the case file by the examining doctor. That means you, the chiropractor handling the care of the case.

Tipping the Scales

As you can see from the above chart, defense methods do not usually use the inventories that you, the treating doc, can and should be using to better document your case file. Add to the chart above, the following issues:

FEATURES OF THE DEFENSE IME:

Diagnosis (DX)  :  A one time, brief exam & DX          

Treatment (TX) rationale:   Never treated the patient              

Photograpy:  Never takes or uses them               

Visual Analog Scaling: Never uses them                                                                                                                                                   

Imaging: Never uses them  

FEATURES OF THE TREATING DOCTOR'S CARE & REPORT:

DX: Best made by the treating doctor.

TX: Only the treating doc knows the case.

TX Ration.: The treating doc knows the best algorythm for this patient.

VAS: Treating doc uses them.

Imaging: Should have images to support care. DACBR over-read very helpful.
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CODING ISSUES: As of 2007, at least in MA, initial examination billing became a big issue. Doctors bills were being cut and indictments were issued for what is called "upcoding" on initial examination CPT submittals. Many DCs were using 99204 "Complete Initial Examination" coding. Although many doctor's offices did fulfill the CPT time and performance qualifications to bill this higher code, it was my recommendation that all docs just down code to 99203 "Detailed Intial Examination" to avoid further hassles with IMEs and Insurance companies. Also, as for electrical stimulation, many docs were using a higher code for this. We it was suggested that docs henceforth use the lower code of 97014 to avoid further hassles.

FIRST DAY REPORTS: As always, we urge in the strongest possible terms that all doctors do a thorough First Day Report. This is a detailed narratve of your first encounter with every single patient, regardless of payment method. Elements of a well composed FDR include the following:

1) Detailed Case History: This should also include past medical issues, operations, medications, past accidents, other doctors seen, etc.
2) Work History: Identify what the patient does/did for work.
3) Picture of the patient
4) General Physical Exam: Include vital signs, Also, the usual gamut of clinical vitals that can be taken in a doctor's office. Also, vertebro-basilar testing should be done along with a Review of Systems (ROS).
5) Palpatory Findings: Note all pathomechanics of the entire spine along with muscle spasm, scars, superficial skin lesions, etc.
6) ROM: Range of motion should be done with instrumentation regardless of payment method.
7) Orthopedic Testing: For all appropriate regions. Include a Dynamometer check of upper body strength.
8) Neurological Testing: Same.
9) Outcome Study: We use the Oswestry Questionaire.
10) Radiological Study: If the doc has an X-Ray or has to order them out, imaging is very important and useful and should be reported on.
11) Diagnosis: A DX should be rendered along with a Differential DX which means a listing of the several best possibilities.
12) Treatment Discussion and Plan of Action: The doctor should discuss his/her methodology, which is to say, he/she should definitively state in the FDR, exactly what type of adjustment system he/she uses, what type of therapy is used and why and discuss the short term plan of action for the patient at hand and why.
13) Prognosis
14) Suggestions
15) Details of any therapy used that first day.

Re-Examinations: The field practitioner should be doing a detailed re-examination every 10 visits or so with each patient. An outcome study should be done on this day along with pertinent ortho and neuro retesting. ROM, dynamometer and vitals should be done as well. In our office we also usually perform Back Power testing to ascertain strengths and weaknesses and deciding if the patient is deconditioned. If so, that usually leads to a rehab regime of treatment which we fully describe. What doctors are NOT doing with their re-examinations is summarizing the data in a brief, usually one page, narrative report. Although it's another report to do, it is worth the time and effort. On that summary narrative, the treating doc can compare new findings to old findings and usually point out any and all improvement. This holds true for the Outcome Studies performed such as the Qswestry Questionaire. This way, anyone examining YOUR file can quickly and easily ascertain the condition of the patient at different points in time during treatment and better assess progress.

*To be continued . . . . . . . .

DR. HABERSTROH IS A BOSTON CHIROPRACTOR AND A SOMERVILLE CHIROPRACTOR.