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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 l.jpg

DOCUMENTATION

STEP BY STEP PROCEDURE

TO GOOD RECORDS


Initial patient forms l.jpg
INITIAL PATIENT FORMS

  • Name, age, sex, address, SS#, Married

  • Consent forms

  • Family history

  • Medical history: surgery, medications

  • Past traumas

  • Visual Analog scale

  • Oswestry forms


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CONSULTATION

  • Go over forms and ask questions

  • Confirm reason for visit

  • Past DC care - what kind, did it help?


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EXAMINATION

  • Chiropractic

    A) palpation

    B) inspection


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ORTHOPEDIC EXAM

  • Range of motion

  • Regional orthopedic tests


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NEUROLOGIC EXAM

  • Sensory

  • Motor

  • DTR

  • Cerebellar

  • Cortical


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RADIOGRAPHIC

  • When and why?

  • Who?

  • What views?

  • Repeat studies


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DIAGNOSIS

  • How to choose?

  • How many to use?

  • When to change?


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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.


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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


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EXAMPLE 1

  • Primary - 847.0

  • Secondary - 723.4

  • Complicating - Arthritis


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EXAMPLE 2

  • Primary - 847.2

  • Secondary - 724.3

  • Complicating - Scoliosis


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EXAMPLE 3

  • Primary - 722.10

  • Secondary - 728.85

  • Complicating - previous surgery


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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.


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CERVICAL SPRAIN/STRAIN

  • Subjective neck pain

  • Affected joint movement painful

  • Spasm or hypertonicity

  • Tenderness by palpation

  • History of trauma/insult to region


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THORACIC SPRAIN/STRAIN

  • Subjective mid-back pain

  • Affected joint movement painful

  • Spasm or hypertonicity

  • Tenderness by palpation

  • History of trauma/insult to region


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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 l.jpg
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


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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


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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


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BRACHIAL PLEXUS LESION353.0

  • Cervical rib

  • Costoclavicular

  • Scalenus anticus syndrome

  • Thoracic outlet syndrome


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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


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ACUTE ACQUIRED TORTICOLLIS = 333.83

  • Acute neck pain - no trauma

  • Spasms usually involving the trapezius or stenocleidomastoideus

  • Head tilt present


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MYOFASCITIS729.1

  • A condition of chronicity

  • Circumscribed palpable nodule (trigger point)

  • Causes referred pain


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HEADACHES784.0

  • Tension

  • Muscular

  • Vertebrogenic

  • Tenderness by palpation in the suboccipital and upper cervical region


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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


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MIGRAINE, CLASSICAL346.0

  • Unilateral head pain

  • Nausea and/or vomiting


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COMMON MIGRAINE346.1

  • Unilateral or bilateral head pain

  • Pain in the eye (stabbing)

  • Often aggravated by light or noise


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WHAT TO BILL?

  • Examination

  • X-rays

  • Manipulation codes

  • Modalities


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DAILY DOCUMENTATION

  • SOAP NOTES

    a) Inappropriate examples

    b) Good examples

    c) Computerized notes


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PROPER DAILY NOTES

  • SOAP FORMAT


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RE-EXAM DOCUMENTATION

  • What to do?

  • How often?

  • What to bill?

  • Now what?

    a) treatment plan change

    b) release from care

    c) referral


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RE-EXAM SHOULD INCLUDE

  • Brief consultation about current condition

  • Repeat (+) tests & significant (-) tests

  • Visual analog scale

  • Oswestry repeated

  • Have patient sign exam form


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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


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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


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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


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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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