Clinical practice in the past ten years has become quite challenging given decreasing fees, government regulations, third party payer hassle-laden policies, creative reimbursement delays and denials, documentation requirements, and a complete change in coding systems (ICD10). As a result of these roadblocks it has become increasingly important to be well-versed in current literature and contemporary guidelines related to the chiropractic profession. Never forget, we are in a war, and evidence/information remain our best weapons. Recently the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) completed an update to the original acute and chronic care guidelines that were published in 2008 and 2010.
The current iteration will be submitted to the National Guideline Clearinghouse and will be seen by payers all over the country. This paper includes a summary of the algorithms that were also published in 2012. So why is any of this important? Simple: by following recommendations included in these documents, especially the current paper, you will have tools to not only document your care, but embark on the most defensible form of case management possible. Today the “process of care” is as important as the documentation. In other words, the manner in which you manage your patient, from the initial consultation and examination to the point of discharge, and everything in between, has come under close scrutiny. You are expected to know, understand, and follow accepted standards in the chiropractic profession. Your mission is to manage your patient, and document the case so well, that it will be very difficult for an independent examiner (IME) or payer to deny your care.
Please consider a few of the most relevant items contained in the current guideline that you need to consider:
- Frequency and duration of trials of chiropractic treatment
- Informed Consent
- Examination procedures
- Severity and duration issues
- Initial Course of treatment
- Re-evaluation and re-examination procedures
- Continuing course of treatment
- Benefit versus Risk analysis
- Outcome measures
- Cautions and contraindications for spinal manipulation
- Conditions requiring co-management or referral
- Chronic care goals
- Therapeutic withdrawal and discharge strategies
- Algorithms/clinical care pathways
- And much, much more.
Remember, knowledge is power. When you become familiar with the important elements represented in this paper you become a case management and documentation warrior. You will have the ammo to shoot back against unjust denials. If you do not fight back, you’ll get run over by a system stacked against you. But once you become known for intelligent and well-documented appeals, the odds of being left alone may drastically improve. Knowledge of, and adherence to these guidelines may result in greater potential for hassle-free reimbursement. When you practice within guidelines the internally generated statistic and adherence reports are in your favor. However, no matter how good you are, there will be cases that extended beyond expected guidelines. And that’s OK. Those are expected given we are working with the human body and not with widgets. But if a high percentage of your cases consistently extend beyond average treatment parameters, you’ll likely be flagged, and reimbursement is often at risk. So it remains important for you to know the game, and become familiar with these guidelines.
Guidelines have several positive attributes:
- Summary of research so you don’t have to read, rate, and sift through that mountain of literature.
- Provides case management and documentation recommendations that, if followed, result in bullet proof documentation, more efficient treatment, and better patient outcomes.
- Provides an easy to use resource that you can draw upon to craft appeals.
For example, without a guideline how would you respond to an IME or reviewer who states, “This is just a sprain/strain, and as such has a natural history of only 6-8 weeks.” If you understand the guidelines, you’ll be able to craft an appeal simply by following the outline of the guideline. You can simply restate the findings of the consult, examination, diagnostics, treatment plan, complicating factors (that often explain why care extended beyond normal guidelines), and most importantly, using the algorithms as your guide, the “progress and response to care,” in addition goals of both the acute and chronic phases of pain management. Proactively providing such clear documentation hampers the ability of an IME or reviewer to deny your care in the first place. But to be effective, you first have to be informed!
My recommendation, read the newest guideline, incorporate these strategies into your current case management process, and fight back when appropriate.
The work of the Clinical Compass Group:
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) has created the Clinical Compass Group. The website has numerous resources available to Doctors of Chiropractic and their staff, for FREE. Check out the Rapid Response Resource Center for information on best practices, and content that can and should be used, to fight inappropriate denials for your patients.
In addition to the newly updated acute and chronic spine care guidelines, the Clinical Compass will be updating even more guidelines. Further, thanks to the vision of Dr. Michele Maiers, Director, Center for Healthcare Innovation and Policy, Northwestern Health Sciences University, the Clinical Compass is working on a collaboration project that involves the Canadian Chiropractic Guideline Initiative, and possibly the European chiropractic and research community, to create a guideline on Outcome Assessment Tools (how to use them) to ensure we can deliver the best care to our patients and quantify that impact more globally. So, expect to see more guidelines from the Clinical Compass in the near future, and get ready for educational webinars to teach you how to use the evidence to fight for your patients and the care they deserve!
References Globe et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. JMPT. January 2016. Article in Press.  Globe et al. Chiropractic Management of Low Back Disorders: Report from a Consensus Process. JMPT November/December 2008. Pages 651-658.  Farabaugh et al. Management of Chronic Spine-related Conditions: Consensus Recommendations of a Multidisciplinary Panel. JMPT. Sept 2010. Volume 33, Number 7. Pages 484-492.  Baker et a. Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain. Topics in Integrative Health Care 2012, Vol. 3(4) ID: 3.4007. Published on December 31, 2012
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