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Well, good day everyone.
Welcome back to another episode with me. Thank you, Chirosecure, and thank you for spending some time with me. I always wanna make your time worthwhile, help your office be a little bit more profitable and more efficient. If nothing else, today’s topic we’re gonna talk about. The chiropractic scope of practice and specifically more about therapies.
And I wanna hit on the two areas. As some of you may be aware, I’m part of the Optum Health Coding and Reimbursement Committee, and one of the things that being appointed to this committee, I want everyone to know. That doesn’t mean I worked for the insurance company. I’m an appointed member, is one of the things they look at is for chiropractic claims and for chiropractic documentation.
what are the common areas that chiropractors run into Problems with, particularly ones that could be audited and there’s gonna be recoupment. So we wanna prevent some of that happening and making sure there’s a good understanding of how do we document therapies, what they mean, who can do them, and so forth.
So let’s go to the slides. Let’s talk about the chiropractic scope of practice and therapies. What do chiropractors. Do, what are they allowed to provide? What services and in fact who may perform them, and really a little bit on how to document them as well. So before I get there though, I wanna bring a little history to this.
I’m a chiropractic legacy. My father was a chiropractor. I’ve been around this my whole life. I’m 62 and I’ve never had nothing but chiropractic be the profession for my family. And when I give you some history, when you think of chiropractic in the sense of therapies and everything else, think of where we’ve come.
And where we can get ourselves to. Obviously there’s been lots of changes that have occurred over time, but for those, I can remember when chiropractic was very back in its infancy and I’d even go back even to the sixties, did we have a lot of issues for people not respecting the profession? I can remember as a time people would say to me, your father’s not a doctor.
And of course I knew what they were trying to intimate, but think of where we’ve changed. You’re all familiar with the show Jeopardy. Take a look. This is one of the most popular shows on tv. Chiropractic is now part of the vernacular. Notice these three questions appeared on a Jeopardy program not long ago, and I wanna point out that’s where chiropractic has come.
So we gotta make sure that we’re ready to continue to move forward because now people understand what we do, how we do. In fact, you wanna see how popular it is? Can you get this one from Wheel of Fortune? Heck, I didn’t get it. It is going to the chiropractor. Think of where we are. in our profession, where we have come from and where we’re going to be.
It really goes back to our origin. What do we do? What is the scope of practice of what chiropractors do? Of course it’s manipulation. That’s the main thing. That’s what you know. , dd Palmer, BJ Palmer, all focused in on, and it’s gonna be in the spinal column mostly, but obviously it could be extra spinal areas, but more than just that, can chiropractors do more than manipulate?
Of course, within the scope of practice for chiropractors, I would say across the us. A chiropractor may perform therapies and therapies. What I mean by that are the physical medicine, physical therapy things, whether it be heat, massage and so forth, and certainly those are things that are gonna be adjunctive to what you do.
Now, can you do them by themselves? Sure. There could be visits where you might do a therapy, only, not manipulation. Maybe a little bit of both. I’d always go back to the main thing we do is manipulate, but certainly therapy’s gonna be a big part of what we do to help facilitate the patient’s recovery. And that includes all of these services on this page.
And I have here just a quick list. This is what we give out in our seminars. You’re probably familiar if you’ve been to minors, something similar where it gives you the common C P T code. You’ll see here we have the chiropractic manipulation first, but then all the physical medicine modalities, whether it’s gonna be supervised or constant attendance.
And we wanna talk a little bit about those in the sense of. What is it that we’re doing? When we’re doing chiropractic, of course it means manipulation. We have four codes, three spinal, one extra spinal, but then we have modalities. Physical medicine services, modalities are things we apply to a patient but don’t have to be there.
And you notice some of ’em are considered supervised, which means you can put them on the patient, don’t have to remain there with them. Okay, great. Just put some heat on, make sure they’re comfortable. Maybe leave it on for 10 minutes. Then we have modalities that are constant attended. Things like electric stem, that’s manual or ultrasound.
Notice these all have time, and I’m gonna make an emphasis here. I do want you to think about time a bit, because obviously these codes can be billed for more than one unit based on the amount of time you spend unattended modalities. It doesn’t matter if you put a hot pack on for an hour, and I’m exaggerating.
doesn’t matter. It’s one unit or if you put it on for 10 minutes. With these though, there is a time limit. The time limit is 15 minutes. You’ll see here also though codes think like for laser, two different codes. Notice S 8 9 48 and 0 5 5 2 T one is a hick pick code. One’s A C P T type two. Nonetheless do cover it in many insurances.
In fact, the VA does in fact cover it. We also have other things that we might do as an adjunct to chiropractic, gonna be therapeutic procedures. And you’ll see here it’s gonna be things like exercise neuromuscular education, massage, manual therapy, therapeutic activities. But you’ll notice all of these also have time.
So again, these are the adjunctive things within scope that chiropractors may do. Now, what I wanna focus in on though is. . There’s a lot of possibilities of services we may do, but I’d really like to dig into what we really do. For instance, when I’m working with an office for the first time and helping them with a fee schedule, I tell them, look, let’s not focus in on a hundred codes cuz you’re not billing a hundred codes.
Let’s talk about the five, six, or seven things you do regularly to make sure we’ve done it right. So what are the common therapies that chiropractors do actually do? Heat of course, but electric stem, that could be manual, meaning hands on or unattended. . There could be ultrasound or other types of electrical therapies including laser, but also things like massage or manual therapy, soft tissue mobilization, manipulation, if you will.
And then of course, the active therapy codes, exercise neuromuscular education. So my reality is most of you are probably beyond doing manipulation, probably having five or six therapy codes that you use regularly. In fact, maybe three very commonly. In fact, if you think of best practices, What are the best practices for neuromusculoskeletal conditions related to chiropractic?
Manipulation of course, but also active therapy. So I’d always say put an emphasis there. However, let’s talk about documenting. This is the issue. What do we have to document when we’re doing a modality? Keep it simple. Tell me what modality you’re doing. . If there’s any type of intensity or range, indicate that.
Tell me where you’re applying it and tell me how long you’re doing it. Keep in mind the best way to document a therapy is document it in a way that someone reading it. Could essentially perform it. So by example, let’s take a look. If I’m doing cervical traction notice this one says Cervical spine distraction.
With harness, it’s intermittent meaning off on at 30 pounds of force for 15 minutes, supplying with a roll support. Clearly, you know what type you’re using here, or infrared heat, nothing fancy. Here I did infrared heat to the lumbar spine for 15 minutes. Now these codes, actually, the amount of time you spend doesn’t change.
The units, but it’s important to know. So you know, did I do it last time for 10 or 15? So as you progress, how about electric stem? Now, electric STEM can be varied. You can do two pads, four pads, tens units. So explain to me what you’re doing. I did bilateral four pads to the trapezius, 50 megahertz for 15 minutes, or to patient tolerance, whatever that might have been, or ultrasound, even think if I told you do ultrasound to the knee, would you know what I actually meant?
Probably not. It’s pretty broad to state it that way, so you know what you want to indicate. I did ultrasound to the patellar tendon. For eight minutes at five intensity. That way, if you think of it, a staff person might be able to follow this or an assistant, and that’s something else we’re gonna get into cuz can you have a staff do some of these?
Let’s focus in on a few more. Let’s talk about massaging manual therapy. Deep tissue work. In some instances would be the manual therapy, but realize they’re very similar. That’s why both these pictures look the same. The major difference is massages, mostly used for relaxation. Whereas manual therapy is usually about range of motion or muscle mobilization.
The nuance is small, but nonetheless, they are separate. In fact, I would say the manual therapy is more of a focal. Therapy, whereas the massage is probably more broad, it’s really more about the outcome. So what do we document here? Tell me what you’re doing it for. What’s the outcome? If I’m doing probably trigger point therapy, why am I doing that?
To reduce the trigger point, but also probably to increase range of motion, increase muscle length compared to massage for relaxation. So tell me what it is and why, where you’re doing it. and any types of assessment that you’re doing for it. And then of course the time. Now you notice here it says, start and stop time.
I’m gonna recommend you do one or the other. Do I wanna do the time I started at 11 o’clock and at 1115 or do I wanna stay just 15 minutes? We’ll talk about that, but either is acceptable. However, I would lean towards putting actual time because chances are you’re spending more than you might realize.
What about another active therapy or an active therapy like exercise, and this is gonna be your standard strength, flexibility, endurance, weight training, if you will, but it’s gonna be a lot of varieties. It could be bikes and treadmills for endurance, gym equipment. Of course, weights, isometric, isotonic, even includes stretching.
Stretching. You may be assisting the patient, but could you also be directing the patient? In other words, it’s to increase strength, increase flexibility, or in fact even increase endurance. So I wanna think along the lines of active therapies, whether it’s gonna be exercised investor education, or any of those time therapies.
We do wanna make sure we are documenting properly time. This is one of the major issues I run into with audits for offices. I will defend you backwards and forwards as long as you have time. If you don’t write time down, it didn’t happen. I’m sure you’ve seen this before. If you didn’t write it down and it didn’t happen, keep that in mind.
Not very hard. Just write it down. Now you’re all probably familiar with the eight minute rule, so I put a synopsis here. Remember a time service though it says 15 minutes. You’ve gotta spend at least eight technically to be billable under the CMS regulation, which has been adopted by every major carrier.
So one unit can be as little as eight. But for a second unit notice it goes to 23 cuz it’s 15 plus eight, hence the 23 minutes. Or if you’re gonna do three units, it has to be two full units, meaning 30 plus eight. So in other words, it can’t work. If I do eight minutes of this one and eight minutes of that one, that would not be a unit of each, because when you’re doing a time service, they become cumulative even if they’re separate.
Because if I spend eight plus eight, it’s only 16 minutes and you notice 16 minutes only is one unit. So do keep in mind whether cumulative or one service, the time must meet the number of units Bill. Now here’s a big issue. We’ve gotta document time. This is the one thing we run into tons of problems with.
People ask me, what do I need to document for time? Let’s hit onto that and let’s focus first on, this is something I get every year we do. In one of our meetings with Optum, we go over where are doctors running into problems, particularly for chiros and documentation. Now, the good news for us is, , we’re actually not as bad as PTs.
PTs have a higher value than we do, but you’ll notice dating back to 2014 to 20, the number one area we have problems with for improper documentation is time services. Now we went down from 64% to 22%, but is a quarter of the time still a good thing? No. That’s gonna be when we’re always gonna get dinged on Get in the habit of time.
So notice here it says, what are the acceptable methods of time? The acceptable methods are a specific number of minutes. Tell me, I did manual therapy by example for 15 minutes, or tell me I went from nine 30 to 9 45. Either is acceptable, but please don’t get in the habit of just checking a box. You spent 15 minutes.
Tell me how much time you really spent, because if you check a box for 15, I go you just wrote that by checking a box. Did you really spend it? I find often when people say they spent 15, they may have spent more. and keep this in mind. What if I do a therapy for 10 minutes and another therapy for 10 minutes?
Can I bill a unit for both? Let’s think about that. If I do 10 plus 10, how many minutes total is that? It’s 20. So how many units is 20? Ooh, only one. But what if I spent 11 minutes plus 12 minutes for 23? Would that allow me to build a unit of each Absolutely. Song. So long as there’s eight minutes on at least one and the rest equals the total time.
So let’s get in the habit of documenting time by telling me how many minutes you have spent, what you wanna avoid, and look at the things here that say acceptable. Look at the unacceptable list writing in terms of units. If you say, I just did two units of exercise, not gonna fly. If you said, Hey, I did from 15 to 23 minutes.
not gonna, they want that number of minutes, not an average. And you can’t just indicate a quantity like I did at times two. Get in the habit of just documenting the number of minutes. Not hard, but it’s something that sometimes, because we were never taught that at first, we don’t like to change. Let’s not be the old dinosaur.
Now. These therapies, can they be done by staff? Now this is something across the 50 states for the most part, that’s going to be true. Staff members can absolutely do therapies under the supervision of the doctor, meaning the chiropractor has evaluated, written up a plan, and then that staff member does it.
The key factor here is proper supervision. For the most part, there’s a few exceptions to this, but for the most part, supervision means you must be in the office at the time the therapy’s being performed. You don’t have to be in the same room looking over them, but within the office suite. So if someone needs information or help from you, you can be there.
The exception would be some California providers are probably aware in California, you actually don’t have to be in the office except 50% of the time. So therefore, if someone is doing massages on Fridays, but you’re not there on Friday, So long as you’re with them, half of their work week, you can still do it.
What I’m gonna wanna make sure everyone knows, learn and assure you, follow your state requirement. This simple, make sure you’re on site, never an issue. And do keep in mind, there are 18 states that will require that. The assistant, if you will, the chiropractic assistant, have certifications. Not many states do that, but just make sure it’s within scope and when they document.
you’re documenting. So make sure that they understand the proper documentation cuz you don’t want to be caught with audits. Don’t make me be the person that comes back and you hire me after the fact. We do a service called the network of course, that when officers get themselves in trouble, they call me, Hey Sam, how do I fix this?
What do I need to do? The malpractice carriers, ChiroSecure and all the major ones, contact me as well. You know what I’d like to do? Let’s make sure your office has done it right the first time. Learn these simple rules. Let me be part of that. We can help you with that. Work on one-on-one share screens via Zoom and other ways to make sure your office is compliant, but more than compliance.
It’s about how much you’re earning. You’re doing the work. Let’s make sure we have it in the right way. And frankly, it’s not hard. Allow me to be that team member with you. Take a look. Go to this QR code for our network, or just take a look at our website, hj ross company.com. We’re here to help with ChiroSecure and with us.
We’re here to make sure your practice thrives and continues to make more money. That’s at the end of the day, you are a business. You wanna be a good doctor. Of course, that’s number one. But you also are a business provider, so we have to make sure on the other side of it, are we doing the things right to make sure we get paid.
I wanna make sure of that. Until next time, everyone, thanks so much for being with me.