We all know that an acute condition has a sudden or short-term onset, and a chronic condition, according to the U.S. National Center for Health Statistics, is a condition that persists for three months or longer. Now if that were all that there was to it, this would be a very short article. However, as with many things in health care, it’s not that simple.
First, we should determine why it matters whether the case is acute or chronic. The Medicare Benefits Policy Manual, Chapter 15, Section 240.1.3 states, “The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam, as described above.”
So, Medicare expects your patient to either recover or show functional improvement, which is the expectation of most third-party payers too. The best way to prove functional improvement is by using outcome assessment questionnaires. These are used at the initial examination to determine the patient’s baseline impairment and again at reexaminations 30 days apart to monitor the patient’s improvement.
The Medicare Benefits Policy Manual, Chapter 15, Section 240.1.3 goes on the state:
“Most spinal joint problems fall into the following categories:
• Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury, identified by X-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.
• Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.”
Since a chronic subluxation is not expected to significantly improve, then it logically follows that an acute subluxation is expected to significantly improve. According to The Clinical Application of Outcomes Assessments by Dr. Steven Yeoman, a score of 11% is the minimum threshold indicating a significant functional impairment. Significant improvement is defined as a 30% improvement between adjacent questionnaires 30 days apart. When you no longer have 30% improvement on an acute case, it is a strong indication that the patient has reached maximum medical improvement. Chronic cases do not need to demonstrate a 30% improvement but do need to show more improvement than the standard deviation between adjacent questionnaires administered 30 days apart.
This is why it matters whether your case is an acute case or a chronic case. If your case is an acute case and you cannot demonstrate 30% functional improvement after 30 days of care, then the patient is considered to be at maximum medical improvement. In contrast, if your case is considered to be a chronic case, then you only have to demonstrate some functional improvement exceeding the standard deviation after 30 days of care. Also, the care is expected to last longer.
The Medicare Benefits Policy Manual, Chapter 15, Section 240.1.5 states: “The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained. Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already ‘set’ and fibrotic tissue has developed. This condition may require a longer treatment time but not with higher frequency.”
Now let us review a sample case to see how this information can be practically applied.
A 52-year-old male presents with low back pain radiating down his right leg to below his knee. He states that the pain occurred when he was bent over in his garden pulling weeds and that nothing like it had happened before. He describes the pain as sharp and lightening-like. Lumbar range of motion is restricted with pain in all planes. Laseque’s and Braggard’s were both positive on the right.
At this point, we would all agree that this is an acute case of lumbar pain with sciatica on the right. But wait, there’s more. Lumbar X-rays indicate disc thinning at the L3 - L4 disc, the L4 - L5 disc, and the L5 -SI disc. It also indicates moderate to severe spurring at the lower margin of L3, the upper and lower margin of L4, the upper and lower margin of L5, and the upper margin of the sacrum.
I believe that we can all agree that it takes more than three months for discs to thin and moderate to severe spurs to form at the vertebral margins. And just like that, your acute case becomes a permanent chronic condition. The protocols now allow for a longer episode of care with a slower rate of improvement, which will change how you treat this case and your prognosis.
The main takeaways from this example are first to be thorough in your exam. Obviously, you don’t want to do more than is necessary, but you don’t want to do less than is necessary either. Failing to collect all the relevant information causes the patient to not receive the care that they need and deserve.
Second, be mindful of the protocols for acute and chronic cases. Treating an acute case utilizing the chronic protocols may cause the patient to be overtreated, resulting in overpayments from the third-party payer and the need to pay them back. Treating a chronic case utilizing acute protocols is potentially worse. This may cause the patient to be undertreated and cause the care to end before the case is properly resolved. The result could be more residual impairments than necessary and more frequent recurrences of the condition.
Note: The chiropractic treatment paradigm is further expanded on in Dr. Short’s new book Chiropractic Documentation. You can purchase this book at: https://store. innovihealth.com/products/chiropractic-documentation
Dr. Ron Short is a 1985 graduate of Palmer College of Chiropractic and is a certified medical compliance specialist, certified professional coder, certified professional compliance officer, certified insurance consultant, and certified peer review specialist. He presents seminars and webinars across the country on Medicare, compliance, coding and billing, and documentation. He has written five books and several articles on Medicare. He is available to speak at your group or association meeting or to assist you with reviews, audits, appeals, or the development of a compliance program for your office. He can be contacted at 217653-5921 or [email protected].
