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DOCUMENTATION. STEP BY STEP PROCEDURE TO GOOD RECORDS. INITIAL PATIENT FORMS. Name, age, sex, address, SS#, Married Consent forms Family history Medical history: surgery, medications Past traumas Visual Analog scale Oswestry forms. CONSULTATION. Go over forms and ask questions

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documentation

DOCUMENTATION

STEP BY STEP PROCEDURE

TO GOOD RECORDS

initial patient forms
INITIAL PATIENT FORMS
  • Name, age, sex, address, SS#, Married
  • Consent forms
  • Family history
  • Medical history: surgery, medications
  • Past traumas
  • Visual Analog scale
  • Oswestry forms
consultation
CONSULTATION
  • Go over forms and ask questions
  • Confirm reason for visit
  • Past DC care - what kind, did it help?
examination
EXAMINATION
  • Chiropractic

A) palpation

B) inspection

orthopedic exam
ORTHOPEDIC EXAM
  • Range of motion
  • Regional orthopedic tests
neurologic exam
NEUROLOGIC EXAM
  • Sensory
  • Motor
  • DTR
  • Cerebellar
  • Cortical
radiographic
RADIOGRAPHIC
  • When and why?
  • Who?
  • What views?
  • Repeat studies
diagnosis
DIAGNOSIS
  • How to choose?
  • How many to use?
  • When to change?
how to choose
HOW TO CHOOSE
  • The diagnosis should be based primarily on the examination information.
  • Secondary information should be the nature of the incident.
  • Generally, the diagnosis should not be based on the radiographic findings.
how many
HOW MANY
  • HCFA forms only have space for 4 codes.
  • Optimize that space
  • List the primary diagnosis first
  • List neurologic diagnosis next
  • List complicating diagnosis last
example 1
EXAMPLE 1
  • Primary - 847.0
  • Secondary - 723.4
  • Complicating - Arthritis
example 2
EXAMPLE 2
  • Primary - 847.2
  • Secondary - 724.3
  • Complicating - Scoliosis
example 3
EXAMPLE 3
  • Primary - 722.10
  • Secondary - 728.85
  • Complicating - previous surgery
when to change
WHEN TO CHANGE
  • When the soft tissue injury has reached MMI.
  • When your care is subluxation based.
  • When the patient is in active rehab.
  • When the condition has worsened.
  • When there is a new injury.
cervical sprain strain
CERVICAL SPRAIN/STRAIN
  • Subjective neck pain
  • Affected joint movement painful
  • Spasm or hypertonicity
  • Tenderness by palpation
  • History of trauma/insult to region
thoracic sprain strain
THORACIC SPRAIN/STRAIN
  • Subjective mid-back pain
  • Affected joint movement painful
  • Spasm or hypertonicity
  • Tenderness by palpation
  • History of trauma/insult to region
lumbar sprain strain 847 2
LUMBAR SPRAIN/STRAIN847.2
  • Subjective low back pain
  • Affected joint movement painful
  • Spasm or hypertonicity
  • Tenderness by palpation
  • History of trauma or insult to region
lumbosacral sprain strain 846 0
LUMBOSACRAL SPRAIN/STRAIN=846.0
  • Subjective low back/sacral pain
  • Affected joint movement painful
  • Spasm or hypertonicity
  • Tenderness by palpation
  • History of trauma or insult to region
cervical disc 722 0
CERVICAL DISC722.0
  • Subjective neck pain
  • Affected joint movement painful
  • Reduced neck motion
  • Spasm or hypertonicity in cervical spine
  • History of trauma
  • Positive cervical compression tests
  • Radicular symptoms
lumbar disc 722 10
LUMBAR DISC722.10
  • Low back, buttock, and/or posterior leg symptoms with at least one of the following positive tests:

A) SLR (+) at 30-70 degrees

B) Bechterew’s test

C) Lasegue’s test

D) Kemp’s test

E) Antalgic posture

brachial plexus lesion 353 0
BRACHIAL PLEXUS LESION353.0
  • Cervical rib
  • Costoclavicular
  • Scalenus anticus syndrome
  • Thoracic outlet syndrome
brachial plexus lesion 353 022
BRACHIAL PLEXUS LESION353.0
  • Tenderness at the supra-clavicular and/or lateral aspect of the lower cervical spine
  • At least one of the following test (+)

A) Adson’s test

B) Wright’s test

C) Costoclavicular test

D) Hyperabduction test

acute acquired torticollis 333 83
ACUTE ACQUIRED TORTICOLLIS = 333.83
  • Acute neck pain - no trauma
  • Spasms usually involving the trapezius or stenocleidomastoideus
  • Head tilt present
myofascitis 729 1
MYOFASCITIS729.1
  • A condition of chronicity
  • Circumscribed palpable nodule (trigger point)
  • Causes referred pain
headaches 784 0
HEADACHES784.0
  • Tension
  • Muscular
  • Vertebrogenic
  • Tenderness by palpation in the suboccipital and upper cervical region
migraine classical 346 0
MIGRAINE, CLASSICAL346.0
  • Aura consisting of at least one of the following:

A) Visual disturbances

B) Numbness or weakness on one side of the body

C) Transient aphasia

D) Vertigo

migraine classical 346 027
MIGRAINE, CLASSICAL346.0
  • Unilateral head pain
  • Nausea and/or vomiting
common migraine 346 1
COMMON MIGRAINE346.1
  • Unilateral or bilateral head pain
  • Pain in the eye (stabbing)
  • Often aggravated by light or noise
what to bill
WHAT TO BILL?
  • Examination
  • X-rays
  • Manipulation codes
  • Modalities
daily documentation
DAILY DOCUMENTATION
  • SOAP NOTES

a) Inappropriate examples

b) Good examples

c) Computerized notes

re exam documentation
RE-EXAM DOCUMENTATION
  • What to do?
  • How often?
  • What to bill?
  • Now what?

a) treatment plan change

b) release from care

c) referral

re exam should include
RE-EXAM SHOULD INCLUDE
  • Brief consultation about current condition
  • Repeat (+) tests & significant (-) tests
  • Visual analog scale
  • Oswestry repeated
  • Have patient sign exam form
re examine how often
RE-EXAMINE HOW OFTEN?
  • Every 10-12 visits
  • Every 4 weeks
  • Whenever there is a worsening of the condition
  • Whenever there is a new area of complaint
  • Upon release from care or MMI
what to bill35
WHAT TO BILL?
  • Simple re-exam - 99211/99212
  • New injury possibly - 99213
  • Significant new injury - 99214

A) Major auto accident with multiple injuries requiring detailed history and detailed examination

now what
NOW WHAT?
  • Treatment plan needs to change
  • If patient is improving the following needs to happen:

A) fewer weekly visits

B) fewer modalities

C) move towards active vs passive care

now what37
NOW WHAT?
  • If the patient has not made significant improvement the following needs to happen:

A) A change in the treatment

B) Referral for second opinion to DC, MD, or DO

C) Additional advanced testing - CT, MRI, EMG

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