By Dr. Alan L. Lyons, D.C.
- FIRST. There are three general disclaimers in the Mercy Guidelines. You need to be familiar with all of them.
1) Page iv. General disclaimers. At the bottom of the second paragraph: "The ultimate judgment regarding the propriety of any specific procedure must be made by the practitioner in light of the individual circumstances presented by each patient."
2) On page 117, the end of the first paragraph: "Their (the Mercy Guidelines) purpose is to assist the clinician in decision making based on the expectations of outcome for the UNCOMPLICATED CASE. They ( the Mercy Guidelines) are NOT designed as a prescriptive or cookbook procedure for determining the absolute frequency of care and the duration of treatment/care for any specific case." (Upper case for emphasis was added)
3) On page 124, VI, RECOMMENDATIONS. "NOTE: Statistical descriptors of treatment frequency, such as mean/median/mode, should NOT be used as a standard to judge care administered to any INDIVIDUAL."
The Mercy Guidelines do NOT say that defense evaluators can use YOUR treatment notes to complete a "plain paper review", then based on YOUR notes disagree with and criticize your recommended treatment plan. In your narratives, or at depositions, hearings or trials, I suggest you recite these disclaimers. In depositions, hearings or trials, have your plaintiff’s attorney ask the "defense evaluator" to read these disclaimers aloud, and then ask him/her what these statements mean. Another interesting quote is on page 119, EPISODE TIME COURSE, "There is universal agreement that of those whose symptoms persist for more than three to four months, more than half (of those patients) Will still be disabled at the end of a year." Also, on page 120, under PASSIVE CARE, "The scientific literature is not helpful in deciding when manual treatment/care should be stopped, either with respect to improvement or worsening of symptoms."
- You must be aware of what the Mercy Guidelines actually say regarding treatment frequency and duration…they do not restrict you to 10 or 12 or 16 visits as some of our favorite "defense evaluators" claim. Review Chapter 8. FREQUENCY and DURATION of CARE. On page 125, E, discusses the UNCOMPLICATED CASE, and recommends treatment guidelines under E, 1, "Significant improvement within 10-14 days; three to five treatments per week." This allows 10 office visits during the first two weeks of care. The Mercy Guidelines do NOT say that a patient needs to be resolved after the first two weeks, they say only that there needs to be obvious improvement at the end of the initial two week chiropractic trial-document this improvement in your chart notes! If your patient is not improving you need to rethink your treatment plan and consider the wisdom of a consultation with some related specialist. In the same paragraph, under #3, Return to Pre-episode status: "six to eight weeks up to three treatments per week." This allows an additional 24 office visits, bringing the total to 34 office visits for the first ten weeks of care.
- . If treatment is still recommended by the treating doctor (the case has not resolved within the first ten weeks of care) the (according to the Mercy Guidelines) the case from uncomplicated to "COMPLICATED". Since the Mercy Guidelines state that they are only designed to offer treatment guidelines for the Uncomplicated Case, now that your case has become "COMPLICATED" it could be argued that the Mercy Guidelines, by their own definition, no longer apply. Regardless, the patient can still be in a subacute status and needing additional care. We then refer to page 125, section F, 2(a). Subacute Episodes. The Mercy Guidelines recommend up to two visits per week. For the length of time at two visits per week we look at section F, 2(d) which says 6-16 weeks, allowing an additional 32 office visits, giving us a total of 66 office visits. [Daily for the first two weeks (10 OV), three times per week for the next 8 weeks (24OV), and two times per week for the next sixteen weks (32OV) for a total of 66 office visits in the first 26 weeks of treatment.]
- . If your patient has not resolved and is not permanent and stationary (or at Maximum Medical Improvement) after the first 16 weeks, the Mercy Guidelines now considers your patient to be "CHRONIC", and is defined on page 125, section 3, CHROIC EPISODES, subsection (a) "Symptom Response: If symptoms have been prolonged beyond 16 weeks" the case becomes classified as chronic. Despite the case becoming "chronic", additional care, if needed, can be provided. Refer to page #121, in the middle of the page, #1. "Patients with chronic disorders may require more treatment/care to resolve symptomatic episodes than other categories of complaints." In that same section, #2, "Lordotic areas of the spine, on average, require twice (2X) the care of complaints involving the thoracic and transitional regions." In view of this modifier, it is the injury involved in a lordotic region, our initial 66 visits is now extended to 132 visits.
- . There are many other treatment modifiers in the Mercy Guidelines, some of which include:
Page 124, section A,1. Short and Long Range Treatment Planning. #1 "Pain more than eight days: Recovery may take 1.5 times longer. Now our 132 office visits becomes 198.
Page 124, section A,2. Typical Severity of Symptoms. "Severe pain : Recovery may take up to two times longer." (198 X 2 = 396)
Page 124, section A, 4. Injury Superimposed on Preexisting Condition(s), Skeletal anomaly: may increase recovery time by 1.5-2 times. (396 X 2 = 794) Structural pathology (e.g., DDD, DJD, ligamentous instability): may increase recovery time by 1.5-2 times (792 X 2 = 1,584)
Therefore, if any of these conditions are present the amount of treatment may be increased…all endorsed by the Mercy Guidelines. DO NOT LET THE MERCY GUIDELINES INTIMIDATE YOU and DO NOT LET THE INSURANCE EVALUATORS or INSURANCE ADJUSTORS MISQUOTE OR TAKE THE MERCY GUIDELINES "OUT OF CONTEXT." When challenged, you need to quote the Mercy Guidelines factually. If you combine that with a good initial exam, timely re-exams, good treatment notes and persistence – you should prevail, your bills should be paid and your patients can receive the treatment they deserve.
Use the appropriate multiplier(s) when the patient presents with the complicating condition(s). Always remember that all treatment MUST BE MEDICALLY NECESSARY.
Dr. Alan L. Lyons, D.C.
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