ADOI has admitted that current law prohibits copayments and deductibles which discriminate against the usual and customary treatment procedures of chiropractors. In an email dated April 24, 2008, Karlene Wenz of ADOI told state representative Andy Tobin that the following proposed legislative language, provided to Rep. Tobin by ACS, "repeats existing language, namely a portion of the first clause of 20-461(B), and thus provides no new protections." The proposed amendment stated: "COPAYMENTS, COINSURANCE AND DEDUCTIBLES MAY BE APPLIED IF THEY DO NOT DISCRIMINATE AGAINST THE USUAL AND CUSTOMARY PROCEDURES OF ANY PHYSICIAN LICENSED PURSUANT TO TITLE 32. CHAPTERS 8, 13, OR 17 WHEN POLICY COVERAGES INCLUDE TREATMENT OF THE CONDITION OR COMPLAINT." These chapters refer to DCs, MDs and DOs.

This means that it is currently illegal for insurance companies to charge higher copays and deductibles for chiropractic procedures than for medical procedures. ADOI knows this practice is widespread at the current time, and yet has taken no enforcement action to halt it. ACS has demanded enforcement from ADOI, and ADOI has stated it can only act if complaints are filed. ACS has initiated "Plan B" which has resulted in a cascade of hundreds of complaints to ADOI, yet no enforcement action has been taken (see http://azchiropractors.org/insurance-laws.html for details). ACS has appealed to the Legislature and so a letter to the Attorney General is forthcoming. This letter, written with ACS research assistance, will ask the AG to enforce the law.

If ADOI does not enforce a law that is within its authority to enforce, a party may file for an administrative hearing to request that ADOI be required to enforce the law. ACS is prepared to do this. If ACS should lose at an administrative hearing, ACS is prepared to take this matter to Superior Court and, if need be, all the way to the Arizona Supreme Court. Never before has such decisive action been taken to enforce this law. The profession will be called upon to unite behind this landmark legal effort.

The facts are now clear. Insurance equality, including non-discriminatory copayments, coinsurance and deductibles, was passed into law in 1990 and 1991. It is currently illegal to charge higher cost sharing for chiropractic procedures than for medical procedures, yet this practice is widespread. ACS is bound and determined to get this law enforced. After all, it was ACS' ancestor organization, the Arizona Chiropractic Alliance (AzCA), which passed this law originally. ACS is not going to let it go down without a fight. If you are not already a member, join now and help support this effort. This is the path that is going to end insurance discrimination once and for all in Arizona, brought to you exclusively by ACS.

Our sponsors are very special to ACS. They help make it possible to bring our written and electronic information to you. They help pay for the ink and postage! Won't you please consider them when you need a service or product? We obviously wouldn't do business with them if we didn't think they were good folks. Please be sure to give them a look. They are supporting your profession and deserve your gratitude for that.

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The E/M (Evaluation and
Management) Exam

by Gregg Friedman, D.C.
ACS Board Member
www.GotDocumentation.com

Ah, the Evaluation and Management codes - let's tackle this beast now.  In a previous article, I wrote about what should be covered in a thorough history of your patient, some of which can be accomplished on your intake forms.  That's the first part of the E/M code.  The second part is the actual examination.

Before I get detailed with the topic of the E/M exam, I need to be clear about a pet peeve (one of many) of mine.  Too many chiropractors are under the false assumption that the E/M exam is all they need to prove medical necessity.  Well, it's not the primary function of the E/M exam is to determine if the patient needs to be referred for additional tests or referred to another specialty.  Let's face it - the medical profession came up with this exam, not chiropractors.

A common question among chiropractors is how to properly bill for the E/M exam. Read what the Arizona Board of Chiropractic Examiners says:

99201 -- 15 minutes of face-to-face time
Problem Focused History - chief complaint; brief history of present illness or problem
Problem Focused Examination - limited examination of the affected body area or organ system
Straight Forward Medical Decision Making - minimal number of diagnoses or management options with minimal amount of data to review and minimal risk of complications

99202 -- 20 minutes of face-to-face time
Expanded Problem Focused History - chief complaint; brief history of present illness and problem pertinent system review
Expanded Problem Focused Examination - limited examination of the affected body area or organ system and other related systems or areas
Straight Forward Medical Decision Making - minimal number of diagnoses or management options with minimal amount of data to review and minimal risk of complications
 
99203 -- 30 minutes of face-to-face time
Detailed History - chief complaint; extended history of present illness; review of systems and areas directly related to the problem identified in the history
Detailed Examination - extended examination of the affected body area and other systems or areas related
Low Complexity Decision Making - minimal number of diagnoses or management options with minimal amount of data to review and minimal risk of complications

99204 -- 45 minutes of face-to-face time
Comprehensive History - chief complaint and a review of the entire affected system and review of all additional body systems; complete past, social and family history
Comprehensive Examination - general multi-system examination or complete examination of an organ system
Moderate Complexity Medical Decision Making - multiple diagnoses or management options with moderate amount of data to review and moderate risk of complications
 
99205 --   60 minutes of face-to-face time
Comprehensive History - chief complaint and a review of the entire affected system and review of all additional body systems; complete past, social and family history
Comprehensive Examination - general multi-system examination or complete examination of an organ system
High Complexity Medical Decision Making - extensive diagnoses or management options with extensive amount of data to review and high risk of complications

Since it doesn't seem like anyone wants to go out on a limb and tell us specifically what we need to do in our exam in order to satisfy any of the above codes, let's look at the differences and see if we can figure it out.  Based on the information above, it appears that a 99201 and 99202 require a pretty minimal history.  If your new patient history constitutes a pretty brief analysis of "how did you hurt your neck?" type of questioning and all additional questions pertain to just the neck following the OPQRST method, you'll be pretty safe within the 99201-99203 codes.  However, if you add to the history questions regarding past, social and family history, you just bumped up into the 99204 arena.  Not so fast, though.

Even if your history qualifies for the 99204 code, but your exam consists of visual range of motion, a few orthopedic tests and some palpation, you just went back down to a 99201 or 99202.  If your examination, though, consists of a visual assessment of range of motion, a motor neurologic exam (deep tendon reflexes, manual muscle testing), a sensory neurologic exam (dermatomal exam with pinwheel), palpation of spasm, tenderness and subluxation, and, oh, yeah, a few orthopedic tests, you might have just leaped back into the 99204 range.  But wait - if your diagnoses consist only of neck pain and cervical segmental dysfunction, guess what just happened?  That's right - you just went down a code or two - again.  But if your exam revealed some abnormalities with regard to muscle strength or dermatomal sensation and you apply the correct diagnoses for these findings, right back up you go.  

Once you get through the history and exam, it's time you took a look at - your time.  Face-to-face time means the amount of time that you (the doctor) are face-to-face with the patient.  On my new patient intake forms, the patient answers most of the questions I would ask during the history, including social, family and past history.  If I sit down with the patient and don't go through all of their answers with them, I am being a poor clinician, not to mention having down-coded my history.  So, I'll go over the entire intake forms with the patient and make any additional notes I need to make.  

My exam consists of a visual assessment of range of motion (for each area of complaint), deep tendon reflexes for the area(s) of complaint, manual muscle testing (for potentially affected nerve roots per area of complaint), dermatomal evaluation with a pinwheel (for each area of complaint), digital palpation for tenderness, spasms and hypomobile subluxations, and, oh, yeah - a few orthopedic tests.  I do this same examination on every patient, not because I want to bill a higher code, but because I am being entrusted with that patient's health and I want to be thorough.  Although it might seem as though that exam might take quite awhile, it doesn't.  I typically get through that exam in about 10 minutes.  A good practice would be to note on the exam form the time in which you began the consultation and the time when the exam was completed.  If you do a great consultation and include social, family and past history, along with the OPQRST format, follow up with a thorough exam and come up with 7 legitimate diagnoses for the patient - but, it took you 30 minutes, I think the appropriate code would be 99203.  If all of that took me 45 minutes, I'd bill the 99204.  

What about the 99205 code?  My answer is just three words:  DON'T USE IT.  To begin with, I've NEVER reviewed a chiropractor's records that satisfied this code.  In addition, when a chiropractor uses the 99205 code, it is a HUGE red flag with both insurance companies and state boards.  If you insist on using this code, you had better be extremely confident that your documentation reflects all that I mentioned above for that code, including the 1 hour of face-to-face time with the patient.  In more than 20 years of practice, I have never used this code.

My recommendation for chiropractic E/M examinations is this:  use thorough intake forms, take a thorough history and do a thorough exam.  Do not limit yourself to 4 diagnoses because of the HCFA/CMS bill - use as many diagnoses as are appropriate.  Document how much face-to-face time you spent with the patient.  Then, bill the appropriate code and sleep peacefully at night, knowing you have done a thorough history and E/M exam of your new patient and have ethically billed for it.

But you still haven't proven medical necessity - bummer.  You'll just have to come to my seminar for that - it's hard to get 12 hours of information into a newsletter! If you have any questions, personally or for future articles, feel free to e-mail me at drgregg@GotDocumentation.com.

ACS Member Performs Life-Saving
CPR on Young Boy

Having just earned his CPR certification two weeks earlier, ACS member Jesus Bernal, DC, performed CPR to resuscitate a two-year-old boy that was pulled from a Tucson.swimming pool May 28, 2008.  KVOA TV Tucson reported:

Authorities say, a father from New Mexico was gathering his five children to leave the pool when one of them fell in. Bernal says he sprang into action after seeing a poolside crowd gather. "I just got in the zone.  I did what I was trained to do.  I did check to see if there was a pulse or breathing.  There was neither." Bernal went on the radio at a local Spanish speaking station the following day to share what happened. "To take a baby without a pulse and not breathing... take him in your hands and do what you were trained to do and bring him back to life. His mother was very grateful.  She was trying to kiss my hand." Bernal says lucky for him, he just earned his CPR certification two weeks ago. His job as a sports physician requires it. "Because of that requirement I was able to save this baby. Bernal is now committed to doing what he can to save more lives. He'll start at the place he works... Rio Rico Health and Wellness Inc. "We are going to offer a laminated sheet with water and summer safety tips that anyone can come and get."

Chiropractic Stroke Scare Campaign Comes to Arizona - Includes Attack on Traditional Chiropractic

Is it Still "Okay" to Be A Chiropractor?

by Erin Chisholm, D.C.
ACS Board Member

As if the current insurance discrimination and board scrutiny aren't enough, we once again get to revisit stroke issues, (the topic that always comes up when the medical community wants to put us back in our place).  Anyone who peruses current news trends is familiar with the Chiropractic Stroke Awareness Group (CSAG).  This is the organization that is working so hard to inform people of the thousands of strokes caused each year by Chiropractors.  Never mind that you can't find any information on who is leading and supporting this organization.  Don't worry that you can't get any good clinical studies or information off their website (and their affiliated websites).  If citing a few malpractice suits constitutes true clinical data, then we all need to be very careful because we are probably causing strokes everyday in our practices.  Maybe we should just stop adjusting peoples' necks to be on the safe side.

Okay, there's my rant - we're all entitled to one.  The truth is there are pressures coming at Arizona chiropractors from all directions.  Add to that a poor economy and many of us are wondering what exactly we should be practicing.  This is a funny statement, because we are chiropractors, so we SHOULD be practicing chiropractic.  But is it still "okay" to be a chiropractor?

CSAG has eloquently noted what we shouldn't be doing if we want to be considered good chiropractors.  Don't function as a Primary Care Doctor.  In fact, you should probably send your patients to a medical doctor to make sure that they are candidates for chiropractic care.  (Although we are portal of entry doctors, required to be able to function as a referring physician in appropriate cases, while practicing within our scope of practice - just like family practitioners.)  Also, recognize that if you can't "cure" a patient in 6 visits or less, then you are a quack and stringing the patient along.  (How many patients have you had come into your office who have been taking prescription narcotics for at least a year?) 

CSAG also lets their audience know that a chiropractor who tells you to get your entire family checked for subluxations is definitely a gold digger.  (If you're one of these charlatans, then you are also probably related to those crazy dentists who suggest that patients get checked on a regular basis for cavities.)  And please do not dare suggest that by getting your spine checked for vertebral subluxations and getting adjusted when indicated, you are preventing possible ill health in the future. 
Obviously, I am saying this all tongue-in-cheek.  I've been under chiropractic care for over 32 years.  Amazingly, I've never had any hospitalizations (other than to have my 3 children).  I do not take medication on a regular basis.  When I was twelve, I went to my first Palmer Lyceum with my father.  That was the point in time that becoming a medical doctor was no longer an option for me.  Not because I think MD's are bad (I know several and they're wonderful).  Not because I couldn't get through the schooling; but because I had found a healthcare solution that made sense and to do anything other than that simply did not. 

When you go to Chiropractic College and they tell you you're going to get to see miracles on a regular basis, they're not lying.  Unfortunately, with the current practice climate, we are sometimes afraid to admit to witnessing these miracles.  We make sure to remember the 5 D's and 3 N's of stroke (diplopia, dizziness, drop attacks, dysarthria, dysphagia, ataxia, nausea, numbness and nystagmus).  We whip out our consent to treat forms and hope that the patients can disregard the fact that we might sprain/strain, fracture, dislocate or possibly even cause a stroke.  We forget that OTC NSAID's cause roughly 7600 deaths per year (and we cause how many?).  Practicing in fear does not benefit our patients and it does not benefit us. 

It's okay to be thorough (full exams and clinical decision making).  It's fantastic to be educated (follow research, stay up-to-date on legislative issues).  It's necessary to adopt smart office procedure in a litigious society (informed consent).  I am a chiropractor.  I started thinking like one when I was 12 years old.  I saw doctors who discussed vertebral subluxation without ducking into a corner.  I heard doctors talk about the mind-body connection, neurology, immunology - that the chiropractic adjustment affects the entire body by allowing the nervous system to function at its optimum potential.  Sure, I'll treat patients for musculoskeletal issues - I can help them.  But I'm not selling out to medicine by becoming something I am not. 

Supporting the ACS is the first step to protecting what we believe in - chiropractic. Oh and by the way, you haven't seen it on the news, but my father, also a chiropractor, possibly saved a man's life several months ago. You see, this man came into the office and was, (guess what?), suffering from symptoms of an oncoming stroke. He got the patient the appropriate care and the patient is doing well.  It's not just "okay" to be a chiropractor. It's a blessing.

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