Guidelines for Growth
MANAGEMENT
Ronald J. Farabaugh
Jay Greenstein
DC, CCSP, CGFI-L1, CKTP
FMS
Clinical practice in the past 10 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 (ICD-10). Because 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 that we ai e in a war, and evidence and information are our best weapons. Recently, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) completed an update1 to the original acute and chronic care guidelines that were published in 2008“ and 2010.1“
The current iteration will be submitted to the National Guideline Clearinghouse, and it will be seen by payers all over the country. This paper includes a summary of the algorithms that were also published in 2012iv. So why is any of this important? It’s simple, really. By following recommendations included in these documents, especially the current paper, you will have tools not only to document your care, but also to 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 eveiything 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 guidelines that you need to consider:
• Frequency and duration of trials of chiropractic treatment
• Infonned consent
• Examination procedures
• Severity and duration issues
• Initial course of treatment
• Réévaluation and reexamination procedures
• Continuing course of treatment
• Benefit versus risk analysis
• Outcome measures
• Cautions and contraindications for spinal manipulation
• Conditions requiring comanagement or referral
• Chronic care goals
• Therapeutic withdrawal and discharge strategies
• Algorithms/clinical care pathways
• And much, much more
Remember that knowledge is power. When you are familial' with tlie 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 be run over by a system stacked against you. Once you become known for intelligent and well-documented appeals, though, 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 ai e in your favor. However, no matter how good you aie, there will be cases that extend beyond expected guidelines, and that’s OK. Those aie expected considering we ai e 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 familial' 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.
• Provide case management and documentation recommendations that, if followed, result in bulletproof documentation, more efficient treatment, and better patient outcomes.
• Provide an easy-to-use resource that you can draw upon to craft appeals.
For example, without guidelines, how would you respond to an IME or reviewer who states, “This is just a sprain/strain, and, as such, it has a natural history of only six to eight weeks.” If you understand the guidelines, you’ll be able to craft an appeal simply by following the outline of the guidelines. 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, the “progress and response to care” while using the algorithms as your guide, in addition to 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 is to read the newest guidelines, incorporate these strategies into your current case-management process, and fight back when appropriate.
The Work of the Clinical Compass:
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) has created the Clinical Compass. The website, www.clinicalcompass.org, has numerous resources available to doctors of chiropractic and then staff members for free. Check out the Rapid Response Resource Center (http://clinicalcompass.org/ resources/rapid-response-resource-center) for information about 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 chr onic spine care guidelines, the Clinical Compass will be updating even more guidelines. Further, thanks to the vision of Dr. Michele Maiers, director of the Center for Healthcare Innovation and Policy at 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 for 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.
7/. Globe et al. Chiropractic Management of Low Back Disorders: Report from a Consensus Process. JMPTNovember/December 2008. Pages 651-658.
Hi. Farabaugh et al. Management of Chronic Spine-related Conditions: Consensus Recommendations of a Multi disciplinary Panel. JMPT. Sept 2010. Volume 33, Number 7. Pages 484-492.
iv. Baker et al. Algorithms for the Chiropractic Management of Acute and Chronic SpineRelated Pain. Topics in Integrative Health Care 2012, Vol. 3(4) ID: 3.4007. Published on December 31, 2012.
Dr. Ronald J. Farabaugh, DC, has been in practice since 1982. Recently he was elected to the Council on Chiropractic Education (CCE), as a Councilor-Category 2, representing clinicians. He isfounder owner ofwww.chiroltd. com, an evidence-based, patient-centered, practice management company dedicated to assisting doctors of chiropractic establish a more evidencebased office and referral mindset. He is also founder of the popular Chiropractic Bootcamp and Practice Revolution. Phone number: 614898-0787. Email address: chironfffaol.com. www. chirocolumbus. com, www. chiroltd. com.
Jay Greenstein, DC is the CEO of the Sport and Spine Companies (www.ssrehab.com) - Sport and Spine Rehab, a multi-location, multi-disciplinary, evidenced-based practice in the Washington DC Metro region: Sport and Spine Athletics, a state-of-theart health and fitness facility: the Sport and Spine Rehab Clinical Research Foundation, a 501-c3 dedicated to high quality, clinical, research: and Kaizenovation® Consulting which coaches businesses on Six Sigma, human capital management and the Entrepreneurial Operating System® (EOS). To contact Dr. Greenstein, email him at drjayffkaizenovate. com.
