I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.

But Dr. Ronald Short beat me to the punch with his outstanding article:
“SOAP: A Chiropractic Perspective” [March 1, 2013 issue], in which he masterfully illustrated the problem. Hopefully, claim reviewers and documentation gurus will finally realize the difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit.

It is important to remember that doctors of chiropractic are unique because we wear two very different hats. First, we are physicians who examine and diagnose (assessment) the patient. Then, after doing so, we carry out our treatment plan by providing care (treatment) to the patient. Failing to realize the distinct difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit places undue, unfair and unnecessary examination and documentation requirements on doctors of chiropractic, and it is time for it to stop.

This problem has been known for years, yet no one has been successful in sensitizing the chiropractic “powers that be” about this unfairness. The American Chiropractic Association’s Clinical Documentation Committee, during the process of authoring the third edition of the ACA Clinical Documentation Manual, attempted to directly address the issue by approving and submitting the following provision:

It is important to understand that the chiropractic physician has two responsibilities to their patients.

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The switch to the new coding system will greatly increase the specificity of diagnostic codes, and most doctors don’t provide enough detail for office coders to translate that to ICD-10, said Rhonda Buckholtz, vice-president of ICD-10 education and training at AAPC, a medical coding society based in Salt Lake City, Utah. Her estimate of the percentage of charts that were inadequately documented came from a survey of patient charts done by the AAPC, but further detail on the survey was not provided.

Doctors have bemoaned the switch to ICD-10 — short for International Classification of Diseases, version 10 — because of the tremendous increase in complexity from the current ICD-9. The number of diagnostic codes will increase from nearly 14,000 to around 69,000. The number of procedure codes will jump from around 3,000 to roughly 87,000.

ICD-10 requires much greater detail on location of ailments, cause and type, and complications or manifestations compared with ICD-9. For example, diabetes will require complications to be incorporated within a single code. And asthma is listed as “mild,” “mild intermittent,” “mild persistent,” “moderate persistent,” or “severe.”

Therefore, Buckholtz said physicians need to start work now to ensure they will provide enough information for billers to properly code.

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At present, the chiropractic profession has difficulty being compliant with Medicare documentation requirements. The 2009 report from the Office of the Inspector General reported the following: “Distinct from the undocumented claims, 83 percent of reviewed chiropractic claims failed to meet one or more of the documentation requirements.

by Steven Yeomans, D.C.

Today more than ever, chiropractors are faced with the challenge of running a busy practice and, at the same time, juggling the documenting requirements in light of Medicare audits, proving “medical necessity” to private insurers, and producing documentation that minimizes risk in this litigious world. The requirement of creating a legible, concise account of the patient encounter that includes patient centered functional goals and methods of tracking functional improvements that occur during care, emphasizes the need for the inclusion of outcomes assessment tools in the documentation process. The goal of this article is to provide you with the “knowledge ammunition” needed to accomplish this task without expending volumes of time and effort.

Outcomes assessment tool availability is not a new concept. Back in the 1970’s, long, impractical outcomes tools surfaced that were too cumbersome for routine use in a primary care setting, but shortly thereafter, in 1980, Fairbank introduced the Oswestry (Low Back) Disability Index (ODI). An interesting point is that the original purpose of the ODI was to identify patients that may require “…positive intervention” in the form of psychological care when scores exceeded 60% (defined as “crippled”).

However, it was (also) found to be an effective tool to be used in serial manner to show patient progress over time and identify endpoints of care or plateaus in progress, prompting a change in the treatment planning for the patient. This was followed by other “gold standard” tools including the Roland-Morris Low Back Disability Questionnaire in 1984, and the chiropractic contribution of Vernon and Mior’s Neck Disability Index in 1988.

A gradual increase in the use of these tools occurred in the 1990’s with introduction of many other condition specific tools for headaches, dizziness, carpal tunnel, shoulder pain, hip, knee, and ankle pain, as well as general health tools, and psychometric tools for depression and anxiety assessment. In fact, there are now so many tools available, it may be quite a challenge to decide which ones are most important.

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For more than a century, chiropractic has largely existed in isolation from mainstream health care, evolving with its own philosophy, system of education and approach to patient care. And, like other groups that develop independently of the mainstream, the profession has created its own unique system of terminology.

The problem is, the terms—namely, preventive, supportive and maintenance care—are poorly understood by allopathic providers, patients and payers alike, which makes it difficult for DCs to communicate the value of their services and, essentially, prevents the profession from fully integrating into mainstream health care. And especially in the past decade, the difference in terminology started to cause problems in the reimbursement arena.

“The government and private payers started designing stages of chiropractic care using their own language and using this as a basis for denying care,” says Ritch Miller, DC, chairman of ACA’s Medicare Committee. “For example, Medicare doesn’t pay for maintenance care—but the definition of maintenance care is so gray that it’s left up to the claims adjusters to decide what it is, and many beneficiaries are wrongly denied care because of the interpretation of these terms,” he adds.

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Sometimes the internal discourse that is common in our profession seems to get in the way of our acceptance of real help so that we can expand our profession and better serve our patients. Alteration of motion segment integrity (AOMSI) is a significant gift from the AMA that allows us to methodically locate, substantiate and objectively prove the severity of the spinal subluxation. Of course, it comes as a gift only as long as we handle it with a high level of responsibility.

Alteration of motion segment integrity is determined by exact mensuration procedure published in the AMA Guides to the Evaluation of Permanent Impairment. It is a spinal subluxation that can be objectively identified with a high degree of accuracy, especially when one acknowledges the advancements that have occurred in assessment of stress imaging (X-ray, DMX).

Please remember that some of the most significant advancements in functional radiology assessment came from information gained from our profession’s very first federal research grant, awarded in the mid 1970s. It was University of Colorado scientist Chung Ha Suh, PhD, who secured the first chiropractic funding from the National Institutes of Health (NS 12226 01A1). Suh’s main areas of research focused on the development of computerized, kinematic models of the spine and three-dimensional, distortion-free X-ray analysis. This research improved our ability to more accurately measure articular deformations such as AOMSI.

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Patient self-perception of the health care experience is becoming an important component of clinical outcomes assessment. In light of the progression toward a more closely managed health care system, chiropractors are being expected to document and quantify clinical progress. Functional health status instruments are an economical & efficient way of accomplishing that task. [1]

The RAND Health Survey measures physical functioning, social functioning, role limitations due to physical problems, role limitations due to emotional problems, sense of emotional well-being, energy/fatigue levels, pain, general health perception, and health change. These questions focus on areas of clinical complaint that many patients are experiencing upon presentation to the chiropractic office.

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These questions are a good example of the interviewing skills required of any doctor:

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You may find value in reviewing templates of these reports.

Initial Report: A General Outline for the D.C.

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Dr. Schafer is the most-published chiropractic author, and his textbooks were best sellers through the 80s and 90s. RC was the first DC author to be picked up by a medical publisher (Williams & Wilkins), and his books made millions for the ACA.

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It is the intention of this section to inform our profession about the most efficient means of communicating patient information, as well as outlining what is considered an “adequate” presentation.

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