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Hi, I am Dr. Mark Studin, and first, I’d like to thank ChiroSecure for allowing me the opportunity to share this information with you. And I am so excited today because we get to talk about documentation of certifying necessary long-term chiropractic care. Let’s go to the screen.
There we go. So what we’re gonna talk about is documenting the necessity of short-term care, long-term care. We’re gonna talk about the demonstrative verification. We’re gonna get into the carrier ruse and assessing participation within those carriers. Now we have a full program, and this is, we only have 30 minutes today, but I’ve spent a few hours doing this.
Then you’ll have an opportunity to really expand your knowledge for CE credit, if you But again, before I move forward, let’s just go and thank our sponsors ChiroSecure. I am the Academy of Chiropractic, and I work with a company. Called inverter, which I do have an interest in for full disclosure.
So I want you to know that even though you’re here today, there’s a lot of people behind you putting this together to give you the information you need. Now, let’s talk about necessity. How does medical necessity affect coverage from a healthcare services? And we’re talking the word necessity. The way your health plan defines medical necessity impacts how it.
Which healthcare services it will pay for, generally health. Health plans pay a portion of the bill for covered services that fit their definition of necessity. Now it’s all provided within their policy, which you really, if you’re an ASEE of benefits or assigned, you should have access to, but it provides.
The diagnosis, treatment, cure, relief of health condition, illness, injury or disease, except for clinical trial trials that are described within the policy and it’s necessary for an appropriate, the diagnosis, treatment, and cure of all of those things. So you’ve gotta have a health condition. It’s gotta have an I C D code, but here’s the.
It has to be within the generally accepted standards of medical care in the community, which is why you find certain political organizations in our industry weighing in on what those definitions are, because the carriers often use those to determine what’s important and or what’s covered and what’s not.
So what are the, what is it really? What do you need to do? You have to provide a letter of medical necessity, which includes ICDs and CPTs that reflect the severity of your pathology, which is the conversation for a different day. Now, your letter of medical necessity is your e and m evaluation.
Evaluation, and. Your initial evaluation, your reevaluation, and you’ve gotta have all those wonderful things in there. We learned in school, O P Q R S D, onset provocation severity time, et cetera. All of those things have to be in there, but then you have to be able to show. , was there anything in the past medical history that could be a comorbidity?
Is there anything within family social review of systems? All of those things are critical. You need a detailed explanation of what your patient is going through. You need a whole bunch of things in there, which are usual and customary in every health industry. Here’s the problem. Because I consult doctors actually in 49 different states.
Over the past two decades, I’ve done honestly thousands of compliance reviews, and I could tell you factually chiropractic’s, dirty little secret is 95% of all of our profession. Cuts corners and has deficient documentation, which can be constituted a violation when you’re dealing with insurance industries.
At the very least, it could cost you getting paid or you’re getting care for your patients. And at the most it could be constituted as fraud. So you’ve gotta ensure that you’re not cutting corners and you’re taking the appropriate time to document. And I know it’s everyone’s least favorite thing, which is I spent a tremendous amount of time with doctors.
on helping them streamline documentation. and sometimes a good EMR system is the solution. Sometimes a good transcription service is the solution and never is a paper appropriate solution on paper ever, because that’s your reputation and your documentation is two things. Compliance, which can cost you your money, your license, or your freedom or your reputation, which can caution you your referrals.
So if you’re on paper, you’re giving up a tremendous amount of referrals. Again, a topic for another. When you get denied, often medical necessity in the carrier’s policy is within the accepted standards in the medical community. And it should be defined in the health plan. And you’ve gotta be careful because there are certain organizations out there.
And this is something you should I believe every state and national organization should mandate full disclosure to the organization. What percentage of your income or what insurance companies they’re working for, because they’re now holding positions within state and national organizations helping to set policy, but now they’re working for insurance companies as highly paid consultants, and they’re saying, we’re not covering this from the insurance company side because they’re working for the state national organization saying it shouldn’t be covered.
and there’s a conflict of interest there, so they’re pointing to themselves, which this is supposed to be an organization representing you and your patients. Now they’re working for the insurance companies also, and that is happening today and in my 42 years within this industry, I’ve seen it over and over again.
And I think there it’s time for full transparency, and I mean that sincerely, because you’re getting denied. Your patients are not getting their care when they should for medically necessary services because the carriers are hiding the fact that they’re paying people to rule against you. And that’s important.
So here’s the next thing you want to do. If you have a, an insurance plan or a managed care plan that pays you 16, 17, 18, 19, $20 a visit and only gives you six visits, do you really want to be in that? Oh, but then they say you could file more paperwork for determination. Now you’re paying someone 20, $30 an hour to file that.
And it could take a long time for them to do that, to get more coverage. And then they deny you again. And then they say, but you could send more information. Then you send more information, which is. Reasonable. And, but we’re gonna explain how the carriers have created a better mouse trap for that. But you’re going in circles and you’re, deny, delay and defend.
That’s the carrier’s mantra. Deny by, by denying the claim, they’ll delay, send this more, deny it again, and then defend it, take to court. So the issue is do you really want to be in a plan? And if there’s, and I could tell you from. If I was in practice today and there was a plan that I knew only covered six visits without mandating more paperwork, there is not a chance in the world I would be involved in that carrier, not at all.
And they’re making a ton of money off of you, a ton of money. So just remember that. Think long and hard before you stay. Now when you look at what the go-to valid. For care, what’s the validation for care? And this is carrier preferred, number one is muscle testing. . Number two is ranges emotion, and number three is indexes.
RY neck pain, low back pain. Those are the three go-tos that the carriers want you to use, and it is a brilliant strategy from them. Brilliant. Because they’re also lumping you together with physical therapists and you are not a physical therapist, and your goals are totally different from physical therapy.
But what the ca, what you are not looking. , and that’s one of the things that’s overlooked by most doctors and the carriers wanna avoid. This is comorbidities. Now what’s a comorbidity? You’re treating them for one disorder. They also have another disorder. Now you have the combined, there are two disorders right here.
A and B that might be totally separate. Two totally different systems, but together it creates an issue such as diabetes or arthritis or whatever. All of these things change or validate the necessity for extended care and everything I’m gonna share with you is evidenced in the literature. Now let’s look at muscle.
The expectation in the chiropractic setting is that proper therapy will immediately improve muscle strength upon manual muscle testing, taking the patient from weak to, to strong. Now, I don’t really have time to delve into that in this form, and in the full program we do. You can learn all about that, but this is why a grading system of muscle evaluation, Does not have as much significance in most chiropractic settings as it does in a physical therapy setting, whose goal is to strengthen the muscle.
Our goal is to stabilize the joint Chiropractic produces rapid responses from the reinnervation of muscles because a basic therapy required for chiropractic patient is the decompression of the nervous system. And again, we don’t have time to expand on this. Is there bone on nerve? Yes. Yes and yes. Is it the nerve root?
No, it’s not the nerve root. We know that you’re getting facets, the nociceptors and the sets, the appropriate receptors and nociceptors and the joint capsule. That’s where all of you bone on nurse. You have the menis, which. The bone space apart and decompress that nerve. That’s where it’s all occurring.
And that is all evidenced in the literature and that’s a whole topic for a different conversation. So therefore, when you render an appropriate chiropractic adjustment, you’re going to rese that MENIS score. You’re gonna take the pressure off of that nerve, you’re gonna relax the joint capsule, it’s gonna stop firing into the lateral horn up the Spinal tract through the per ductal gray area, thema ping pong around the anterior ula cortex, the prefrontal cortex, the motor cortex, the sensory cortex hypothalamus go fer down to muscles, often in disparate areas to create biomechanical homeostasis, and it’ll strengthen the muscle.
So therefore, almost instantly you’re going to have increased muscles, but the muscles are also not balanced to hold in the right place, and it’s going to pull back. You’re gonna have that meniscal, also unseeded, because the joint is not used to being stabilized. They’re still biomechanical failure. And if Wolf’s law came into play and the bone is remodeled, then it’s gonna constantly go back to the wrong position.
Now. Is a five hour conversation to explain it in detail, but at least you’ve heard it. And hopefully I’ll do it enough. You’ll understand it. But instantly the muscles are gonna start to get strong again and range of motion’s gonna start to come back because range of motion. Is not the, we’ll talk about range of motion in a minute.
Physical therapy which I’m not gonna explain in this conversation, does not receive the facet, meniscal or normalize mechanical receptors, OSIS and nociception. He relies the physiological mechanism, as I explained for the renovation. So physical therapy wants to strengthen strength and strength, and you’re done in chiropractic.
When you decompress those nerves, the mechanism I just explained, the muscles are gonna strengthen, but the spasms are gonna start to relax. It sounds like an oxymoron. The spasms in the body’s gonna. all it’s going to, it’s gonna shift the, it’s gonna relax and then the muscles will strengthen in the right place very quickly.
But it doesn’t mean the spine is stabilized. So therefore, the next thing we’re going to use, okay we’re talking about muscle testing. Number two is actually ranges of motion. It shouldn’t be number three. We look at range of motion and then range of motion. Normalizing range of motion when it’s decreased to normal.
Is that the goal? Guess what? It isn’t, but where’s your demonstrable evidence for range of motion? One is a two piece inclinometer. You cannot eyeball it according to Thema Guide’s evaluation Permit Impairment fifth edition, page 406th edition refers back to the fifth edition for range of motion. It says, you must use a two piece C inclinometer.
Not a goniometer. Not an arthro. Protractor visually can only say normal or restricted. So if you want numbers, you need a two piece clinometer. You could use George’s. with x-ray and this came out in the 1920s or x-ray, digitizing and x-rays are safe. You could, before you have, according to the evidence in the literature, and it’s all over the literature, not just one little piece.
For you to have a negative incident from radiation in a, in, in, in any setting, you need to have 5,000 cervical x-rays. I think. 60 thoracic x-rays and 57 lumbar x-rays. Don’t quote me, but the numbers are close. Actually it’s 5,000 cervical, a hundred thoracic and 57 lumbar x-rays at one time. No one does that.
It’s absurd. So X-ray is not an issue. You know the sky isn’t falling. We talked about the range of motion. Now watch if the person can go 45 degrees. Inflection. Is it normal? , is it a hundred percent normal globally? Yes. But is it a normal range of motion and I su and I offer to you? Probably not. So if you look at this person, you are seeing a 45 degree flexion.
Okay, and by the way, I apologize, you’re seeing the side of my face. I’m looking at a second screen on where my slides are. A computer nerd. I have four screens in front of me, but 45 degrees is normal, what you see here, but it’s fused at C five six. How could this be normal? So let’s look at this, each motor unit, segmentally, and let’s look at these and the numbers aren’t exact because I did this for academic purposes, but C two three is six degrees.
C3 four, six degrees, 16 degrees. That’s abnormal. C4, five 14 degrees abnormal C five six fused. In the front, it’s negative five degrees and C6 seven is 14 degrees. It adds up to 45 degrees, but four outta five motor units are abnormal. The problem isn’t too little. The problem is too much. When the ligaments start to impair and when the ligaments impair.
Now you’ve got a problem. And there are tools to be able to determine that subverted is one of those emanating or measuring tools that tells you where there’s normal versus abnormal. Be able to seek and verify and validate the necessity for long-term care. The last thing we’re gonna look at is indexes.
We talked about muscle testing, range of motion. Now we’re gonna talk about indexes, Oswestry. Neck pain index low back index. There are issues with those. First they are called psychometric tests or self-reporting. A psychometric test is any activity or assessment that is conducted to evaluated candidate’s performance and includes, but is not limited to skills, knowledgeability personality traits, attitudes, and job academic potential where they fill it out themselves.
And you look at US Westy, low back, neck pain disability index. And by the way, an index, when they did the research based upon the evidence in the literature, there’s about 30,000 people they did this on. And you might say, oh, the more people the better. And that is true for research, and that was done in an occupational setting.
But what about my. . What if my patient doesn’t fit all the way to the left or all the way to the right? It’s gotta be where my patient is today. So when we look at. According to the Scandinavian Journal of journal of Surgery, they said there is no gold standard for measuring functional disability with spinal problems.
Ostry can be used to monitor the response to treatment of rehab, and it’s based on the patient’s subjective impression of their own state or disability. We looked at a research article in 2017 on shoulder. Indexes, I’m sorry, on shoulder performance indexes and the authors wrote that not only is it not valid, It’s not valid because they did not look at normals and they did not look at treatment because everyone gets different treatment for different things.
So it’s a big, it’s a significant problem when you look at these standards, there’s no gold standard for that. Now, am I saying it’s a bad thing? No. Would I use that for my patient only once if the carrier mandated this as part of their policy? But you know what, I’m gonna. Mrs. Jones used to be able to carry her baby for 30 minutes.
Now she can only carry her baby after she injured her spine or hurt herself for five minutes. Next visit, next reevaluation. Now she could carry her baby for 12 minutes or 18 minutes. Mr. Jones was a mechanic. , he used to be able to reach over the, under the hood of the car with a wrench and tighten it.
Since he hurt himself, he can no longer reach over and pull a wrench. He’s changed the job from a mechanic to a service writer. So now I’m, keep it real. And where did I learn that from? I learned that from a judge in New York State Supreme Court, who ruled on a significant number of my cases that I testified on, and he said he quoted every single time the real life scenario of the.
So when you look at the patient, okay, and you look at cohorts cohort in the scientific world is the number of people. In the study, Oswestry back pain, neck pain indexes are a cohort of fat, tens of thousands. Mine is a cohort of one. My patient tell me what my patient can and can’t do. So when you’re looking at the carriers want to bring you down that garden path to use an index.
They’re actually stacking the deck against you. So you’re getting an OSWESTRY score of 49, 30 out of 50. Let’s do that. Okay. That’s your Oswestry. Okay. You’re in front of me and you’re on the witness stand. Say, let’s proverbially. Doctor, can you please tell me what your patient can do on a 32 versus a 30 on the US West Street?
What can they do in real life? And your answer is no. You can. I promise you, you can’t. Can you tell me what your patient can do less on a 28 out of 30? That versus a 30? You can’t keep it real. And when you keep it real, there’s, it’s transparent. It’s black and white. There’s no way for anyone to say that the patient’s not progressing through care, because that’s also a prime parameter to determine mri.
Are they progressing through care? And that’s important. Now, let’s talk about comorbidities and demonstrably. Remember the word demonstrably? You have to be able to demonstrably validate these things. You have comorbidities as hypothyroidism, smoking. Cardiovascular disease, diabetes. But let’s talk about degenerative disc disease, and I’m not gonna say arthritis because that’s not the appropriate term.
It’s arthropathy. It’s a it’s pathology within the joint. Which is bone disc bone, but we’re gonna talk about degenerative disc disease and there is a tremendous amount of evidence in the literature, and according to these folks in 2017, they wrote. in the absence of motor deficit, cuz if there’s motor deficit, they’re considering disc surgery in the ap.
In the absence of motor deficits, a non-operative course of analgesia, drugs, activity modification, bedrest, and injections should be tried for several months. Months. But yet managed care companies are giving us six visits over a week and a half or two weeks. So medicine’s evidence-based. Requires months of care.
Whereas many chiropractic managed care companies lost six visits and requests an unreasonable amount of documentation for the visits, making it cost effective to render necessary care, make wise decisions in your business to continue with those companies, but nonetheless, months of care. And it’s also based in the algorithm of carriers using the appropriate ICD and CPTs, and many of you are reluctant to.
Degenerative disc disease or those types of genre of diseases of arthropathy, because they’re gonna say it’s preexisting. You know what? It’s okay to say things are preexisting because it’s a comorbidity, but in your notes you have to clearly define as a result of the preexisting issue.
This is gonna make treatment longer. And there is also coding where you could. A codes and S codes and D codes, which I’m not gonna get into now to talk about. Is it initial care? Is it sequela care? All these different things, which tell more of a complete story. Now let’s look at a mathematical demonstrative formula for determining disc degeneration.
So actually what the evidence of the literature, this just came out in 2021. It’s very new. It says, and I’m gonna say what it says here, simply, if you take the height of the disc and multiply it by, It should be greater than the height of the posterior vertebra below. So 18 times three is 54, which is higher than 35.
That’s a healthy disc, but the disc below you measure at the center portion of the disc. This is eight millimeters, so if you take eight times three is 24, which is less than 41 millimeters, so therefore it is degenerative. 24 is less than 41. This is a degenerative disc. According to this article in 2017, it was on degenerative disc disease can take months of care, and that should go in a macro citing your evidence and showing your demonstrative verification of where the comorbidity is, explaining why you’re gonna need more.
And that needs to be put with an A code. Your treatment showing its initial care, showing why it’s gonna take longer. Add your degenerative disc disease diagnoses in. Now, one of the things that I’ve done is I’ve taken watch is this degenerative disc disease here. Cause there’s a. No, this isn’t degenerative disc disease.
This is an arthropathy of the joint of the vertebra of c1. 2, 3, 4, 5, let’s, C5 disc is degenerative disc disease. It look at the height, it’s less, so don’t be confused between bone spurs and disc. And by the way the natural sequela is you’re going to. Disc, you’re gonna have a bones where it’s just a matter of time and it often starts in the posterior portion.
And there’s a whole host of other things in the spine, but let’s not get into that. Now we’re gonna look at sim Verta. What Subverted does, which is an x-ray and you go to subverted.com it does a whole lot of things. It gives you a o m ssi which can gives you impairment ratings. It tells you where the ADI Atlanta Dental interval is.
It gives you biomechanical validation. All of these things for another conversation. It gives you biomechanical validation of where care is specifically and when a patient’s getting better gives you a lot. But here’s another thing it does. We’re measuring and it’s menstruating. Each vertebra, the tool measures the center height of each disc comparatively to the posterior height of the.
We digitize the disc height to demonstratively, validate normal versus pathological. So again, this is demonstrative, it’s third party evidence. You’re using a digitizing system and you get a report that looks like this. Here’s your pathology line. This is the disc height. Everything to the right of this green line is normal because the disc height is more than one third or 30%, 33% of the height of the inferior vertebra, so C two three.
Right up here. C 23, non-pathological c3. Four to the right of the green line, non-pathological. C 45 to the right of the green line. Non-pathological. C 56 to the right of the green line. Non-pathological C 67. The disc is deficient. It’s short, it’s degenerated. Now you have a pathological disc and you could report it as because it actually gives you demonstrable information.
So folks, we wanna make everything demonstrable. And what we have found when dealing with the courts, when we deal with attorneys and PI cases, workers comp cases, or we’re dealing with insurance. What they don’t like is when you have demonstrative validation. When you have demonstrative validation showing why you’re right and why that patient needs more care, you’ve got the appropriate ICD and C P T codes that crosslink, you’ve got it all.
There’s very little they could do other than say we just don’t want to pay. And you know what, if I have a company. That is denying me. After six visits, I’m go, I’m not gonna fill out their a hundred page form. It’s absurd. I would say there is a comorbidity of disc degeneration. The evidence in the literature says that it takes longer.
That’s why this patient needs more. Now the carrier’s comebacks gonna say you didn’t fill out our form for muscle testing and range of motion. That’s what we use and indexes. That’s what we use to determine more. They’re ignoring the physiological facts that are all evidence in the literature.
Do you want to be with that company and determine if that company has people that is retained, who are also within your political systems in state and federal levels? And that’s a huge issue and I’m the only one in the industry discussing that. And that needs to be a household conversation in all 50 states, organizations and national organizations.
There needs to be transparency. So the truth can be told in the meantime. You want to automate your demonstrative validation. It just makes it easy. So listen, the most accurate progress evaluation you have, and I said this before, it’s a cohort of one. Your patient. Your patient. How is your patient doing?
Keep it real. Keep it real. Keep it. So if you want a full program, you can go to teach doctors.com. This course at the course’s name will be Coding and Care Plan from Acute Through Rehabilitation. That’s the name of this full course. You could do that. You could always contact me. You go to teach doctors.com.
It’ll be my pleasure to chat with you at any time. Here’s where you could reach me. Here’s my cell phone number if you want to take your phone out and take a picture of that. I’m more than happy to chat with you. It’s my pleasure. So listen I’m Dr. Mark Studin again. I would love to thank Cairo Secure for the privilege of sharing this information.
It’s just a whole lot of fun. Thank you so much. We’ll see you next time.