Medicare Documentation: Part 1 Subluxation and the Initial Visit

VIEW PRINT VERSION

Joe Betz, B.S., D.C

ICA Board Member,

PCCRP Board Member

Private Practice Boise, ID

Idaho Chiropractic Association Board Member

CBP Instructor

&

Jason Jaeger, DC

ICA Assembly Representative for NV

Nevada Chiropractic Association Board Member

CBP Instructor

Private Practice Las Vegas, NV

INTRODUCTION

            Few things in daily practice are more time consuming and seemingly non-productive than time spent on documenting daily visits of patients. Perhaps the most concerning aspect of documentation pertains to the regulations on how to document appropriately for the Medicare daily visit. Doctors are being audited at alarmingly high rates. Audits from the Office of the Inspector General can result in the Chiropractor owing >$300, 000…all due to poor records. This isn’t exactly what one would consider malicious fraud, but it can result in serious repercussions.

Subluxation Documentation

The good news is that Medicare has defined what elements a clinical record from a chiropractor must contain for both the “Initial” and “Subsequent” encounters.¹ It should first be stated that covered benefits for chiropractic are “only for treatment by means of manual and instrument manipulation of the spine to correct a subluxation.”¹ Of note is the fact that Medicare requires the term, “Subluxation” be used in the treating chiropractor’s documentation.  Exclusive use of other terms such “fixation” is not adequate.

A subluxation may be demonstrated by an X-ray and/or by physical examination. Although there are exceptions, the X-ray should have been taken at most 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. Demonstrating the presence of a subluxation by physical examination is described in detail. The “PART” format is the acronym to remember the essential elements of the physical exam to demonstrate a subluxation: “Pain/tenderness evaluated in terms of location, quality, and intensity; Asymmetry/misalignment identified on a sectional or segmental level; Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility);and Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, skin, fascia, muscle, and ligament.” ¹

The manual continues, “To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under “physical examination” are required, one of which must be asymmetry/misalignment or range of motion abnormality.”¹ The history recorded in the patient record should include the following:

“Symptoms causing patient to seek treatment; Family history if relevant; Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history); Mechanism of trauma; Quality and character of symptoms/problem; Onset, duration, intensity, frequency, location and radiation of symptoms; Aggravating or relieving factors; and Prior interventions, treatments, medications, secondary complaints.”¹

Subluxation Documentation Requirements

“The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination [Emphasis Added]:

1. Description of the present illness including: Mechanism of trauma; Quality and character of symptoms/problem; Onset, duration, intensity, frequency, location, and radiation of symptoms;

DISCUSSION

It is important to note that individual states may have additional regulations described by their Medicare Administrative Contractor (MAC) in the form of a Local Coverage Determination (LCD).

The language used in the Medicare Benefit Policy Manual is precise in what is required. If you are not following Medicare’s described documentation requirements for the Initial visit on each and every Medicare patient, you are vulnerable to poor performance “when” (not “if”) they audit your records. You must own this information or suffer the consequences.

Electronic Health Record (EHR) systems that are properly designed will aid the chiropractor in documenting the Initial visit for a Medicare visit appropriately. This is perhaps the single most important aspect of choosing the proper EHR. Who are the clinical advisors? Do they understand the reality of Medicare documentation requirements? Be sure you can produce compliant notes, quickly and with confidence.

A system such as this would simplify the doctor’s life, the staff requirements. A system like this would set the clinic using it, above and apart from the rest.

SUMMARY

To realize this unprecedented professional standard now required by Medicare, CBP has partnered with a well known-respected EHR Company to develop a system specifically for CBP and corrective care doctors. This system will debut at the 2012 CBP Annual conference in Scottsdale, AZ at the Boulders Resort. See the annual conference ad in this issue or go to www.idealspine.com for registration.

References

1. Medicare Benefit Policy Manual. Chapter 15 Section 240. Chiropractic Services.

Knee Pain and Foot Orthotics

Stuart Currie DC,

Director of Research, Sole Supports. 

www.solesupports.com  

INTRODUCTION

            There is an intuitive link in the kinetic chain between the foot and the knee, resulting in the common clinical practice of prescribing custom-made foot orthotics for patients with various types of knee pain.

Subjective knee pain is one thing that may prompt a clinician to think about foot orthotics in their treatment plan. There is an assumed relationship between feet and knees and a comprehensive knee evaluation considers both proximal and distal structures. What is relevant to the clinician is a determination of the root cause of the knee pain and whether foot pathology may be involved. While there are no hard and fast rules or substitute for a thorough history and physical exam, there are a few clues that can help determine the origin. 

A Few Clinical Clues

The first case is asymmetric knee pain with asymmetric pronation. When the knee pain is on the same side as the pronated foot, there is reason to look at the ipsi-lateral foot as the cause. Figure 1 illustrates pronation of the right foot, subsequent internal rotation of the tibia and femur with the consequent alteration in knee orientation and function. Pronation can and should be evaluated both statically and dynamically. Tests such as the navicular drop test, and walking or treadmill gait analysis can help determine if knee pain is a result of altered foot posture. When evaluating the effects pronation has on the knee, be sure to observe the patella and its orientation relative to pronation that may or may not be happening concomitantly.

Bilateral knee pain with a bilateral valgus knee posture that is alleviated by active or assisted supination of the foot can also be an indicator that knee pain is related to foot posture. While often not a long term solution, taping the arch or a prefabricated insert is an inexpensive way to determine if changing foot function might have positive effects on knee pain.

 

Once an initial assessment has been made and a determination that a corrected foot posture is required to address the root cause of the knee pain, a custom orthotic can be a valuable tool. The effects of orthotics on the knee have been demonstrated with a kinematic and kinetic investigation revealing that molded orthotics reduced vertical loading rate and ankle inversion moment and increased maximum foot inversion and maximum knee external rotation moment (1).

Knee Pain and Foot Orthoses

Knee pain can be complex and the different causes of knee pain must be considered separately when considering an orthotic device. The response of knee pain to orthotic devices has been described as “individualistic” and “nonsystemic” (2) implying that care must be used in both patient and treatment selection.

With regards to knee osteoarthritis, there is some debate in the literature regarding the effectiveness of various devices. Traditionally, a laterally wedged insert has been used – theoretically offloading the medial compartment of the knee. A review of the literature on lateral wedges reveals positive, negative and equivocal results. With regards to a custom orthotic with full contact medial support, there is a theoretical basis for utilization. It has been shown that the plantar center of pressure (of the foot) in patients with medial knee OA has shown a high lateral loading component (3). In other words, people with symptomatic medial knee OA load the lateral aspect of their foot to a greater degree. Considering this information with investigations that have shown a medial shift of plantar pressure with a full contact, MASS position custom orthotic (4), there is a basis for controlling aberrant foot loading resulting in more optimal knee function in this patient population.

When comparing flat versus contoured foot orthoses, it has been shown that patients perceive more support through the heel and arch regions with a contoured support (2). In addition, subjects in the patellofemoral pain group reported a clinically significant reduction in knee pain as a result of wearing foot orthoses (2). Another study showed that custom made orthoses were an effective treatment to reduce the symptoms of patellofemoral pain (5)

The reasons for the improvements seen with a custom foot orthotic are more difficult to ascertain. Foot postural factors are thought to play a role. Kinetics and kinematics of the foot and lower limb (such as tibial internal rotation) may be involved. “Emerging evidence suggests that orthotics, specific shoe types and footwear interventions may provide an effective nonsurgical intervention in rheumatic diseases. Yet good data are sparse, and it is premature to recommend guidelines” (6). 

The concept that foot mobility plays a role in the etiology of knee pain and the success of any treatment outcome has long been assumed. A recent study showed that foot mobility is related to knee pain outcomes; with results indicating that orthotics provide greater improvements in anterior knee pain than a wait-and-see approach and that individuals with greater mid-foot mobility are more likely to experience success from treatment (7). This underlines the importance of the evaluation of foot flexibility and mobility in the physical exam for prediction of treatment outcomes.

SUMMARY

In summary, while there is a need for further investigation into the mechanisms of knee pain as it relates to foot posture, there is evidence for the utilization of foot orthotics as one part of a comprehensive treatment plan. 

References

1) Mundermann, A., (2003) Clin. Biomech. (Bristol., Avon.) 18, 254-262.

2) McPoil, T. G., (2011) J. Am. Podiatr. Med. Assoc. 101, 7-16.

3) Lidtke, R. H., (2010) J.Am. Podiatr. Med. Assoc. 100, 178-184..

4) Hodgon, B., (2006) Journal of Sport and Rehabilitation 15, 33-44.

5) Munuera, P. V., (2011) Prosthet. Orthot. Int. 35, 342-349.

6) Riskowski, J., (2011) Curr. Opin. Rheumatol. 23, 148-155.

7) Mills, K.,(2010).Br.J.Sports Med. 44, 1035-1046.

The Omega-6/Omega-3 Ratio and Innate Neurological Function

Dan Murphy, DC—

Private Practice of Chiropractic;
Diplomate American Board of Chiropractic Orthopedist;
Faculty Life Chiropractic College West;
Vice President ICA 2003-2009;

ICA Chiropractor of the Year 2009

INTRODUCTION

Chiropractors pride themselves on improving the function of the nervous system by improving spinal mechanical integrity. However, it is also know that optimal neurological function requires a narrow, innate balance of omega-6 / omega-3 fatty acids. A recent article by physician and geneticist Artemis Simopoulos explores this relationship, and I have reviewed her article below:

Evolutionary Aspects of Diet: The Omega-6/Omega-3 Ratio and the Brain Molecular Neurobiology October, 2011; Vol. 44; No. 2; pp. 203-215

• ·      LA = linoleic acid (plant derived omega-6 fatty acid)
• ·      ALA = alpha linolenic acid (plant derived omega-3 fatty acid)

Dr. Simopoulos cites a number of sources indicating that human beings evolved on a diet that had a ratio of omega-6 to omega-3 fatty acids (FA) of about 1/1. Today, Western diets may have a ratio 25/1. Western diets are deficient in omega-3 FA compared with the diet on which humans evolved and their genetic patterns were established.

Omega-6 and omega-3 FA are important components of practically all cell membranes. The omega-3 FA docosahexaenoic acid (DHA) is essential for the normal functional development of the brain and retina. DHA accounts for 40% of the membrane phospholipid FA in the brain.

The omega-3 FAs eicosapentaenoic acid (EPA) and DHA have an effect on membrane receptor function and even neurotransmitter generation and metabolism.

The balance of omega-6 and omega-3 FA is important for homeostasis and normal development throughout the life cycle.

KEY POINTS FROM THIS STUDY INCLUDE:

1. Nutrition is an environmental factor that influences gene expression.
2. Major changes have taken place in our diet over the past 10,000 years since the beginning of the Agricultural Revolution, but our genes have not changed.
3. The major changes that have taken place in our diets in the past 10,000 years include:

a)     An increase in energy intake and decrease in energy expenditure;

b)    An increase in saturated fat;

c)     An increase in omega-6 fatty acids;

d)    An increase in trans-fatty acids;

e)     An increase in cereal grains;

f)     An increase in fruit and vegetable intake;

g)     A decrease in omega-3 fatty acid intake;

h)    A decrease in complex carbohydrate intake;

i)      A decrease in fiber intake;

j)      A decrease in protein;

k)    A decrease in antioxidants;

l)      A decrease in vitamin D;

m)   A decrease in calcium intake.

1. “The beneficial health effects of omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were described first in the Greenland Eskimos who consumed a high seafood diet and had low rates of coronary heart disease, asthma, type 1 diabetes mellitus, and multiple sclerosis. Since that observation, the beneficial health effects of omega-3 fatty acids have been extended to include benefits related to cancer, inflammatory bowel disease, rheumatoid arthritis, psoriasis, and mental health.”
2. The change of omega-6/omega-3 ratio in the food supply of Western societies has occurred over the last 150 years.
3. “During evolution, omega-3 fatty acids were found in all foods consumed: meat, wild plants, eggs, fish, nuts, and berries.”
4. Today in Western societies the omega-6/omega-3 ratio is very high due to the high intake of soybean oil, corn oil, sunflower, safflower, and linseed oil.
5. The omega-6/omega-3 ratio is associated with normal “growth and development, as well as in the outcome of hypertension, cancer, arthritis, mental health, allergies and other autoimmune diseases,” as well as the “pathophysiology of atherosclerosis, inflammation, and aging.”
6. “DHA is found in high amounts in the membranes of brain and retina and is critical for proper neurogenesis, neurotransmitter metabolism, neuroprotection and vision. The consumption of high amounts of DHA has been associated with multiple health benefits including brain and retinal development, aging, memory formation, synaptic membrane function, photoreceptor biogenesis and function, and neuroprotection. DHA is essential for pre-natal brain development.”
7. Omega-3s cause apoptotic death in cancer cells whereas omega-6s allowed the cancer cells to continue to proliferate. 
8. Diets with a high omega-6/omega-3 ratio may enhance the risk for both depression and inflammatory diseases.
9. “Clinical studies show that cognitive performance improves with omega-3’s.”
10. Omega-3’s can affect not only cognitive functions, but also mood and emotional states and may act as a mood stabilizer. Omega-3’s have beneficial effects in some neurological diseases in addition to the chronic fatigue syndrome.
11. Omega-3 deficiency in childhood delays brain development, and produces irreversible effects, while the same deficiency in aging accelerates the deterioration of brain function.
12. Omega-3 intake from ALA does not provide adequate intakes of EPA and DHA.
13. “Western diets are characterized by high omega-6 and low omega-3 fatty acid intake, whereas during the Paleolithic period when human’s genetic profile was established, there was a balance between omega-6 and omega-3 fatty acids. Therefore, humans today live in a nutritional environment that differs from that for which our genetic constitution was selected.”
14. “The balance of omega-6/omega-3 fatty acids is an important determinant in maintaining homeostasis, normal development, and mental health throughout the life cycle.”
15. The AA/EPA ratio has been proposed as an index for the omega-6/omega-3 ratio.
16. Omega-3 deficiency in the brain is associated with “decreased learning ability, with a lower synaptic vesicle density in the hippocampus; whereas, chronic administration of omega-3’s improves reference memory-related learning probably due to increased neuroplasticity of the neural membranes.”
17. “Cognitive performance improves with omega-3’s supplementation possibly due to increased hippocampal acetylcholine levels, the anti-inflammatory effects of omega-3’s, decreased risk of cardiovascular disease or increased neuroplasticity.”
18. Omega-3 fatty acids have positive effects in patients with dementia, schizophrenia, depression and other central nervous systems diseases.
19. Omega-3 fatty acid supplementation could play a role in reduced hostility and violence.
20. “In carrying out clinical intervention trials, it is essential to increase the omega-3 and decrease the omega-6 fatty acid intake in order to have a balanced omega-6 to omega-3 intake.”
21. “In humans, the brain is the most outstanding organ in biological development: it follows that the priority is brain growth and development, and in the brain the balance between omega-6 and omega-3 PUFA metabolites is close to 1:1. This ratio should be the target for human nutrition.”
22. “The ratio of omega-6/omega-3 fatty acids in the brain between 1:1 and 2:1 is in agreement with the data from the evolutionary aspects of diet and genetics.”
23. “A ratio of 1:1 to 2:1 omega-6/omega-3 fatty acids should be the target ratio for health.”

COMMENTS FROM DAN MURPHY

The omega-6/omega-3 fatty acid ratio (AA/EPA) is innately critical for brain function, heart health, immunity, joint health, pain syndromes and more. I believe that everyone should have the AA/EPA ratio tested to see if they are in the “target ratio” of 1-2/1, AA/EPA.

Several labs offer testing of the AA/EPA ratio. The test is called Bloodspot Fatty Acids 0241. The test is a finger prick draw, not venipuncture. If you would like information on the lab I personally recommend, contact me at dan@danmurphydc.com.

Some nutritional companies offer more optimal ratios of ALA, EPA, DHA, and GLA. If you would like information on the omega-3 oils I personally recommend and take for myself, contact me at dan@danmurphydc.com.

The target ratio’s of EPA/DHA is different for children and adults. To achieve their “target ratio” most adults need to consume 3,000 mg/day of EPA+DHA