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Hi, I am Dr. Mark Studin, and today we’re gonna talk about wellness. Documentation and diagnosing. We’re really gonna dig into what it’s doing either for you or to you and to the chiropractic profession. Let’s go to the slides and we’ll get into further detail. So we’re gonna be talking about diagnosing demonstrative documentation.
Triaging. We’re gonna talk about all the fun things we need to do about getting paid and advancing chiropractic, and it’s really important and it’s a problem. So before we get started, I know towards the end everybody wants to run. Take your phone out, take a picture of my contact information. There’s a QR code if you wanna learn more about us, but I’m more than happy to have a conversation with you.
To have an email conversation with you whenever you need. It’s my pleasure if it helps chiropractic. So documentation is about three things. Reimbursement, which affects your income compliance, which can cost you your money, your license, or your freedom and your reputation, which has to do with referrals.
Even wellness has to do with all three of those things because . If you do something wrong in the insurance world, the patients complaint to the carriers and they make a financial calculation if they should investigate you. But cash patients in a wellness scenario only have one place to go. That’s your licenser licensure board.
They go right to the board at the state level, and by law, virtually every state is mandated to have an investigation. And they’re brutal. They don’t. They don’t. They’re short on resources, so they like to make examples often. The fines are steep. They suspend licenses. They do a lot of different things, and if they feel you’re hurting someone, they’re it’s a significant issue.
So you’ve gotta be really careful about your documentation. Now, what we do in the Academy of Chiropractic, you’re document, we make it easy. Your documentation should be incredibly easy, and it’s not hard. It really isn’t, because when I onboard a new consulting client, The first thing we do is a full compliance review.
We look at documentation and we are awfully concerned with those living in the wellness world. And now we’ve got those chiro doc in the boxes, the chiros for a cheap fee. Come right, get adjustment and leave. No appointment necessary. We’re starting to see problems all over the place, especially in the malpractice arena.
We’re seeing issues. It should be easy now. Here is how horrible documentation destroys your practice and the chiropractic profession. A lawyer sent this to me, actually when I wrote it was today, it was three days ago as part of an ongoing case. It was a record sent by a chiropractor, as the chiropractor also had no identifying information on this document.
This lawyer sent it to his lawyer friends and he is gonna bring it to the local Bar Association meeting next week or next month as the joke of the month. But the punchline is look at what all chiropractors do. Look at this documentation. This was sent to me by a chiropractor. It was a personal injury case.
The chiropractor did not touch the patient. He did not do personal injury. It was wellness, but this was part of his records, and the patient had seen him in the past. Now the lawyer gets this, and this is the crap this doctor sends out. But what happens is when a medical doctor makes a stupid mistake like this, oh, that MD says he’s an idiot, but when a chiropractor makes that mistake, all of chiropractic is no good.
And that’s an issue. So by sending documents out, you’ve gotta be careful. Actually I’m in New York and in New York, they enacted a law a few years ago, a regulation because an infant in the neonate unit was supposed to give 0.3 milligrams of potassium, and they gave three milligrams.
They couldn’t see the decimal point and the baby died. So it’s actually a licensure violation and to not have legible notes amongst other things. Now, if we look at. How wellness documentation destroys your practice profession. Let’s take a really good look at this document. Okay, so if we look at this document, let me just, I’m sorry, I’m scrolling around.
I apologize. There’s a lot of elements in here, and the first thing I want you to notice is there’s no SS for subjective. There’s nothing we’re gonna talk about that in a little bit. But there is no SS for subjective and we’ll get to that. But understand there was 152 wellness visits over eight years.
There was one initial evaluation and this was it. Okay and by the way, if I’m turning my head, I’m working on multiple monitors reading off a different screen. His subjective, John saw treatment today complaining. A frequent aching discomfort in the low back. He rated the intensity of discomfort using a V A ss.
I don’t know if that’s SS derin or visual analog scale because there is no key for the acronyms. As a level four, on a scale of one to 10, there’s no such thing as a one to 10 scale. A visual analog scale is zero to 10, so you’ve perjured yourself. The discomfort was reported to increase with movement, applied pressure, and prolonged sitting.
The discomfort was reported to decrease with rest and movement. This is perfectly fine other than the one to 10 to only treat the low back. It’s a hard rule for every area you touch. You need a symptom, a clinical finding, and a diagnosis. But let’s move on. Objective. Spinal restrictions or subluxation.
The subluxation is not a clinical finding, it’s a diagnostic conclusion. You can have motion palpation, ABER movement, spasm hyperemia, anything. Those are the components of what you’re finding. And L three four. So far we’re consistent pain and tenderness. No pain reported or elicited? No Pain reported.
He reported low back pain here. Post analysis, short leg. Now, muscle spasms in the lumbar area, which contradicts this range of motion. Entire lumbar spine is within normal writ limits without pain noted. Okay, during the range of motion, his assessment, there is no diagnosis here. Zippity Dodo. Current status, asymptomatic.
He’s very symptomatic. This looks like this person just cut and paste from a last report. Didn’t even look complaints, no complaint presented. This is nonsense. You have complaints up here. Chiropractic, manipulative therapy. I have a hard time using the word manipulation. It’s not a philosophical issue. If you ever get pulled into court, doctor, are you a physical therapist?
Are you an osteopath? They manipulate you. It just takes that argument off the table. Just use a chiropractic spinal adjustment and there is no argument. Primary treatment. Okay? And following expert extra spinal regions well, Where’s the treatment order? You have to have a treatment order. This is an E N m visit.
Management is the m. Where’s the treatment plan? There is not, but it gets better. Okay, and we, I just highlighted everything that I just discussed. All of these things have to be talked about and the word John. Doctor, do you have relations with John when you’re done and do you bat your eyelashes? It sounds absurd.
Mr. Jones, only us demented chiropractors use familiar first name because it gives an air of prejudice that you’re not talking about a patient objectively. And then here’s a soap note. Okay. The first of all, subjective, and I’m not gonna be able to explain this in depth this forum does not allow us to but we have primary spine care programs.
And if you go to that QR code again, I’ll show it again in the back. There are programs which can help you. You can elicit a response. Patient elicited, which is taught, I teach at three chiropractic colleges and two medical schools at various levels. You’re eliciting a response patient at to run your hand down the spine taught tend to fibers elicited a pain of scale of one outta 10, two outta 10.
Subjective muscle spasticity, hyperemia, whatever you want. Motion palpation. I don’t care. Okay. That gives you that response. But this person for 152 wellness visits had the exact same thing. This was the only change. T two left sacrum and then they changed it here and here. Could be C one C six whatever it is that changed over 152 visits.
No other clinical findings, never a diagnosis. For every area you touch, you need a symptom. It can be elicited, a clinical finding and a diagnosis that is a hard rule that could cost you your license, it could cost you your money. It could eventually cost you your freedom if you’re doing it over patient, after patient, and you get involved in a criminal RICO case.
Or it might just be civil because you’re using a paper instrument to defraud an an insurance company. If this is an insurance, Scenario or insurance patient, but it doesn’t matter the financial class of the patient, whether it’s cash or insurance, it’s the same documentation. It doesn’t change. It doesn’t change ever.
So we just talked about this. For every region treated, you need a symptom of clinical finding and a diagnosis. Miga missing elements can cost you in cash. Patients licensure violations, fines insurance fraud, or RICO under the organized racketeering act for insurance. You’ve gotta be real careful. So this patient, as I said a moment ago, was in a car crash at the end of the eighth year of wellness gear.
The lawyers issued a subpoenas deuces, teum subpoenas. Deuces tecum is a order for records and that you have to, by law submit that to the attorney, which I got. So why does a lawyer issue a subpoena? Duces T’S subpoenas records. It’s easy to distribute to all the plaintiff and defense experts. Once the lawyer has it, the plaintiff expert, which was me, gets a copy of this, but so does the defense experts.
Now, in the beginning of every expert report, experts are required to list or put in the report how they derived at their conclusion. The one that I did, here’s my sample report. I had a list of radiologists, the hospital department, the neuroradiologist, the neurosurgeon, the primary care provider, another radiologist a neurologist, an interventional pain management, a neurosurgeon the chiropractor, and a pt.
All of these people got ahold of the exact same notes. Every one of these people, every one. 152 saw this, and this, all 152 records. So here’s what the plaintiff lawyer said. Now I know why I’ll never use a chiropractor. I no longer want their referrals because I’m stuck with them. Here’s what the defense lawyer said.
I love working with these people. They never use the word doctor, by the way, because I went almost every case with this typical type of documentation from chiros. Typical. The primary care medical rock doctor wrote, what a joke. I don’t care about. The reported outcomes. They look like failed therapists.
The radiologist said not even an x-ray, and they had ous findings. The neuroradiologist said myelopathic findings and no M R I. They probably didn’t even know. They probably don’t even know what myelopathy is. By the way is core compression with ensuing neurological deficit, dis level of lesion. You need to know that.
Like the back of the hand, I’m afraid these patients will get hurt. The pain management doctor said myelopathic findings and no M R I. This is scary and should be malpractice. This is why you refer to PTs. At least they don’t hurt these patients. The neurologist. The neurosurgeon and the second neurosurgeon said the same thing as the pain management doctor and the head and neck surgeon, by the way, who’s my cousin?
He actually . Weighed in on this. He said in the operating room, as I am opening for anterior approach fusions for the neurosurgeons, all the surgeons talk about is the chiropractor should not be doctors, is they never diagnose correctly and hurt people. They always skip the process. Physical therapists love it ’cause it’s great for their referrals.
So folks, here’s the research. You ready? According to Blanche in 2016, they found that. Chiropractors versus physical therapy. In the occupational side, there’s a 313% increased disability, secondary disability. When PTs, the first provider versus chiropractic, there’s a 239% full compensation or disability greater.
When PTs the first versus chiropractic, you know what all these doctors say? They don’t care. They don’t care why? A research soundbite does not overcome the evidence. I see over and over in chiropractic’s documentation. There are no shortcut folks. There’s a reason why we’re mired in a 7% utilization.
Listen, it’s about your reputation, the clinic’s reputation. You wanna shoot yourself between the eyes. I could care less, but it’s about my profession’s reputation. And we do live in a cancel culture and we, that’s just the way it is, and there is no trust. The rest of us who are doing it differently and have gone not just the extra mile, but the extra hundreds of miles and hours and days and weeks and years to get better, we’re humiliated.
We’re just humiliated when we see stuff like I showed you, which unfortunately is more of the rule and not the exception. So we’ve got to be able to manage our reputation. Reputation management. It’s the single most important piece of practice growth. It’s what they think of you. My wife had cancer three times and she’s doing great now.
She had kidney cancer, but we had to find the right urologist, the kidney surgeon, and we went to the person. We, I went from Boston to New York. To Philly to Washington, and I looked at these doctor’s cvs, but I wanted the person with the best reputation, not with the best ad, but not what the other patient said.
That patient might’ve done great, but 10 others might’ve died. I want this doctor’s reputation from other doctors. I wanna look at their curriculum vitae. I wanna look at what they’ve done. All reputation or the reputation business that drives your referrals. So I’m not interested in how you about how you feel chiropractic about chiropractic.
I can’t change that. But if I change what then you’ll change how you feel. That’s in relationships. I feel you. Take me for granted. The wife tells the husband, I don’t I feel dismissed. I feel transparent. The husband said, I love you. I love you. The wife says, it doesn’t matter.
That’s how I feel. You can’t change that. All of a sudden, you’re opening the door to the car. When they get in the car, you hold the chair. When they go sit, you hold their hand while you’re walking. Now you’re changing what they see and it changes how you feel. We are no different. There are things we do like in very basics.
When you’re documenting history, you have to do history of present illness, review of systems, past family, social, okay? I don’t care if you’re doing a 9, 9, 2 0 2, and it’s brief. You don’t have to. You don’t have to. Who do you need to make happy if it’s insurance to pay for reimbursement? Your licensure might want these things down.
Patient care is important to understand these things. But collaborating MDs and referrals referring lawyers, it’s critical to really function at this level for everything. Listen, a neurologist does this. It’s very brief past medical history gerd, H L D current meds, social history, medical records.
This is typical of what but for us, it’s not enough. We’re mired in 7%. Utilization. And I know people say it’s more, I challenge them to validate that it went up to 10 at 1% at one point, but I think we’re back in seven. It doesn’t matter. Orthos, neuros, neurosurgeon, medical primaries, they’re seeing 99% of the population I want to tie into this, so I gotta make them happy and happy.
Endings in our industry equals referrals. You make ’em happy, they refer. I can’t change how you feel, only what so when I do when I do a report and I just did a report for that attorney I talked about with the crappy records. When I shared with you, when I tell you that I did a robust report, I delved into past medical history.
Like a starving man after a T-bone steak. I delved into it. I made sure I had a complete review of systems. Everything the lawyers said, I quote, I’ve never seen this complete a history before. What you wrote about past medical history changed my case. I will now get the entire policy, which is over a million dollars more a result.
He’s already referred five new cases to me in two weeks. Two of his lawyer colleagues called me to refer me more cases. I don’t even have an office. He said to me, if you treated patients, I would close your practice out on a heartbeat. You would never have enough space. Because not only myself, but every attorney here, I would send tell them only you.
Only you. So I want to share with you if you change what they see, you’ll change how they feel. It’s simple. This process of reputation management has also worked with doctors who’ve had licensure issues in the past. Legal issues we’re talking about fraud, felony. We’re talking about battery.
We’re talking about a million people who’ve served time. In fact, it’s taken me about two years. We’ve rebuilt their reputation, we’ve done it through advanced credentials and other things, and all these doctors are now getting PI referrals from lawyers. So it could do that with you. Just gimme a jingle and it’s my pleasure to help you get through that.
Simple, not hard, but this is the type of thing that you need to look at when you’re doing your allergies, meds, review of system. Robust. How long does this take? No. Or yes. Review of previous treatments, family, social history, pre-existing. Every E M R system has this on paper, which you shouldn’t be.
You should be in an E M R system ’cause things should be typed. It’s robust and it’s easy. When you’re doing things, by the way, follow the new e and m guidelines in 2021. I do not care if you’re cash, the same guidelines, the same coding, the same everything. Okay? And remember, 9 9 2 0 3 is the same code as a 9 9 2 1 4.
I covered this in a previous slide and I think I’ve got it covered. So folks listen. , take your phone out before we switch off of the screen. Take a picture if you need to contact me. It is my pleasure to share any of this information with you. Call anytime and thank you ChiroSecure so much for giving me the platform to sharing this.
Thank you and have a great day. .