Asking for Referrals: It’s As Simple As That

Students, like doctors, like to see patients. We all like to be busy and help as many people as we can. One simple way of staying busy in clinic (and a good lesson to learn for practice) is simply to ask patients for referrals. 

A lot of students and doctors are uncomfortable about the idea of asking patients for referrals. They feel like it comes off as “desperate” or that it is confrontational. Asking for referrals certainly can be both, but when done properly and with the right intent, it is easy, ethical and a great way to build your practice through your existing patient base.

When you are new in practice, you often have the misconception that if you simply take good care of people, “they will take care of you.” This is a nice idea, and it is more or less true (in the long run), but in the meantime you can’t sit around waiting! Keep in mind that many, if not most, of your patients don’t even know you would like to be busier in your practice, or that you have appointment slots available in your day… how can they unless you tell them?

To illustrate this, let me tell you a quick story about my practice. I set up practice in a medium sized town in Michigan that was loaded with chiropractors. I was not from the town (or even from Michigan), and I had no friends, family or contacts there. When I started my practice, I started with exactly zero patients and built it into a successful practice with lots and lots of very hard work. About three years after I’d been in practice, a new MD moved into the empty office space next to mine. We hit it off and had a great working relationship for several years. When he opened up, he mentioned, “Yeah, Priority Health transferred over 600 patients to me, but you know, it takes a while for them to start coming in, so I just have to tough it out for a month or so…”

Sure enough, in a month or so he was doing pretty well for himself. He didn’t market, advertise, speak anywhere, or do anything. He simply had patients referred to him by the HMO’s he was participating with! Wouldn’t it be nice if it were so easy for chiropractors to build a practice?! But, it isn’t. At the same time, patients are used to having trouble making appointments with their medical doctor, and he and the staff often mention how “slammed” they’ve been, how much paperwork is mounting up, how they couldn’t take another patient if they wanted to, etc.

Things are very different for chiropractors (for one, HMO’s exert a lot less pressure on us than our medical counterparts, and we have a lot more freedom in practice as a result), but your patients won’t know unless you tell them. So, make a habit of telling your patients that your goal is to help as many people in your community as possible, and the only way you can achieve that goal is for your patient to refer friends or family members who may be good candidates for chiropractic care.

Do it consistently for at least one month, and you will be very surprised by the results. You don’t have to ask for phone numbers and cold call people, etc. Simply tell them you have more space in your day for more patients and that you would love to take care of someone close to them, and you’ll see the results you are looking for as long as you give it some time and are consistent with your asking. 

When a new patient comes in, be sure to track how they found out about your practice and send a handwritten thank you note to the referring patient. I used to include a $15 gift card to Barnes & Noble along with the note, and it worked wonders.

Documentation: Taking the Pain Out of the Process

Unfortunately, this doesn’t apply so much to your time in the clinic right now, but part of your job in clinic should be also planning for the future, so it never hurts to do that, too, right? Last post was all about the reasons why good documentation are so critically important to a good health care practice. This post is about some of the different ways of taking the pain out of the process of keeping your notes so that you don’t have to spend as much time recording the information that is so important for you to keep.

Of course, anyone going into practice today needs to look at all of the available options in terms of record-keeping. Right now there are two basic ways to keep your files and records: electronically and paper. They have their pros and cons, and electronic records are more complicated, require a safe network for HIPAA, require constant backups and remote backups for the event of an office or computer disaster (which will happen at some point), etc. But, the trend in insurance is that the standard is switching to EMR (electronic medical records), so it behooves you to really look at all the options for EMR that are out there. You can spend a lot of money on a software system for your office, so make sure you do all your homework and settle on something that works, is user-friendly, does what it is supposed to do, is well-supported, and meets all of the privacy standards being set forth by Medicare.

Most of these systems utilize a tablet PC or a PalmPilot type of device that you use while working with your patient. There are check boxes, pull down menus, etc that once you are really familiar with the system save you a lot of time. The software can generally spit out all sorts of narratives and other reports as needed for insurance and file audit purposes, too, but you do have to be careful about “canned” reports as the insurance companies can spot them from a mile away and, while not illegal or unethical, can create some unneeded problems for you. 

Your best bet is to attend a large state or national convention and really spend some time in the expo area. Those guys are there to make sales, so make sure they take you through every aspect of the program and how it all works, and discusses all of the costs (there are startup and yearly maintenance fees, too, that can range from several hundred to several thousand dollars) with you. Take your own notes on your likes and dislikes because at a large convention there could be 25+ software vendors there. Be sure to ask about national standards and if they meet them, what updates and upgrades cost, etc.

Also, go online and Google search “EMR chiropractic” and see all the possibilities. Watch the demos and contact the companies for more information (they usually don’t have pricing right on the webpage, unfortunately). There is only one Mac-native software I am aware of (MacPractice), which looks phenomenal, but is very expensive, but don’t think you have to have a PC for this!

Another alternative for people not ready to jump straight into EMR is to use shorthand when taking histories and recording your SOAP notes, then setting aside time a few times a day to dictate your notes. Dragon Naturally Speaking and MacSpeech are two excellent dictation software packages that allow you to speak your notes instead of write or type them. So, you can transfer your shorthand into speech and let the software “type” it out for you. Then you can save it in the patient’s file or print and add it to their paper file. This is a huge time-saver, but ultimately, all records are going to need to be EMR, so this option simply puts off the inevitable.

Also, don’t be afraid to look outside of the chiropractic profession at medical options, too. A lot of these systems are built more or less the same way and simply are tailored to one profession or another, but with some changes and some presets changed are frequently totally usable by any health care provider. So, if you don’t see the product or the price you are looking for in chiropractic, see what else is out there for medical offices.

The Fallacy of Cash Practice

Yesterday, a frustrated student said to me, “I’m just gonna go cash so I don’t have to do all this,” referring to the SOAP notes you do on each patient visit. I had a good internal chuckle and tried to set him straight, but I’ve heard this many times from students and even more often from doctors, so it’s a good topic to get out there.

Yes, keeping good notes is not fun. Almost everyone I know would agree that it is time-consuming and frustrating because the amount of information required of doctors in general (but chiropractors, especially), is always increasing, and some of it seems sort of redundant. 

We have good reason to stress the importance of taking good notes, though. In 2007, Medicare released a document stating that something like 94% of chiropractors’ documentation was “inadequate.” To the best of my knowledge, the nature of these inadequacies wasn’t outlined, but the point is that your documentation supports what you are doing, and it is used to get paid by the insurance company.

Do you really want an insurance company asking for all the money they’ve paid you, plus interest, back on services because your documentation doesn’t support your billing? It happens! If you think that is bad, think about the idea of federal fraud charges on top of that, from Medicare’s legal wing. This is why I always recommend to use charts and coding books when it comes to ICD-9 diagnosis and CPT® procedure codes. Using the wrong one can result in a disaster, and the excuse of “I didn’t know” or “Oops, I made a mistake” goes about as far as you can throw a 400-pound gorilla with Medicare and insurance companies.

Because of this, students and doctors alike think that they can avoid “all the work” by “going cash.” As if having a cash practice is easy to do for a new doctor, anyway! Why would someone pay a new graduate out of their pocket when they can see an experienced doctor and use their insurance right down the road? A doctor tried doing this in Holland, MI, where I practiced for seven years. He opened up right across the street, and closed less than a year later. We had 25 chiropractic offices in a town of 38,000 people. Duh.

Besides, a cash practice is not a panacea when it comes to documentation. Certainly a lot of the notes doctors keep now are mainly to appease the insurance companies, but let’s look at this scenario: Mrs. Jones comes in for an adjustment, you provide the service and charge $45 up front. She gives you the money, you provide a receipt and everyone is happy. Mrs. Jones then turns around and submits your receipt to her insurance company. That insurance company can now access your records of Mrs. Johns and ask for copies of your notes if it wants. Let’s say they reimburse Mrs. Jones over a 6-month period of coming to you, then they ask for your notes, and you send them copies of the cocktail napkins or whatever you use to scribble on in your cash practice… if they decide the notes are inadequate, they can pressure Mrs. Jones to return the money they reimbursed her, and she could turn right around a sue you. If your notes stink, guess what?

Another reason to take good notes is to protect yourself. People love to sue one another in this country. The student in question that was bent out of shape because I told him he needed better notes had written “WNL” in the space for Range of Motion in the objective assessment area. Yet he adjusted 2-3 segments on the patient. So, let’s say Mrs. Jones feels like she wants to sue you for malpractice. With bad notes your malpractice insurance company would never let you go to court, anyway, but let’s pretend the case did get that far…

Attorney: So, Dr. X, tell me what an adjustment supposedly does.

You: We look at motion restrictions in the spine and other joints and the adjustment restores normal function and motion into the area that was having problems.

Attorney: I see. And this is what you did with Mrs. Jones on July 22, 2008?

You: Yes.

Attorney: Can you explain to me what you found that day when you adjusted Mrs. Jones?

You: Yes. She had restricted motion at C5, so I adjusted her there.

Attorney: I see. And we’re just supposed to believe you, huh?

You: What do you mean?

Attorney: Your daily notes for that day read, “Range of Motion, WNL”

You: Well, I meant global range of motion.

Attorney: The globe has a range of motion?

You: No, I mean her range of motion was normal in the neck, overall.

Attorney: So why did she need an adjustment?

You: Because C5 wasn’t moving properly.

Attorney: But you said her neck was moving normal, so why did you adjust her?

You: Because…

Attorney: Are you aware that biomechanical studies have shown that 10% of extension in the neck comes from the C5/C6 motor unit?

You: Um, yeah, YEAH, I remember that, but…

Attorney: Well, actually, that’s wrong. It’s 15%. What DO you know about what you do, MISTER X?

And so it goes. Good documentation is required of all doctors for a variety of reasons. You need it to support your billing, to get paid and keep that what is paid to you. You need it to protect yourself in the event of a lawsuit. If it isn’t written down, it didn’t happen. It’s as simple as that. Finally, it’s good patient care. Good notes let you know, in detail, how your patient is progressing, what is working and what isn’t, and if your plan is working. If your plan isn’t working, your notes tell you what you need to do to help that patient. It isn’t rocket science, but it is work, and it’s work you just have to get used to.

Next article will be on ways in practice that you can streamline the act of taking your notes so it doesn’t take 15 minutes for each patient.

Knowledge + Practice = Skill

I was recently reading a magazine article about professional training schools for shooting, of all things, and the author wrote something that really stuck with me:

Books and DVDs on shooting are useful, but they provide knowledge, not skill. Skill is derived from the combination of knowledge and practice.

There are obvious differences between shooting guns and taking care of patients, but this idea still holds true for both. This also applies across the board of the profession of being a chiropractor, not just to adjusting.

In class, you gain knowledge. Seminars, books, articles, websites, blogs… they all give you knowledge, but reading about adjusting a patient, taking a case history, performing examination procedures, or managing a business, for example, is a lot different from actually doing it. On the other side of the coin, doing a lot of things, without the knowledge of why or what you are trying to accomplish, also yields less-than-wonderful results.

For example, I could grab anyone off the street and ask them to take a case history on my patient, and they’ll talk to the patient for a while, maybe even ask some of the right questions, but they’re not going to do as good of a job as someone with the knowledge that it takes to know what information they want to gather.

So, true skill is the marriage of knowledge (strong academics or “book learnin’”) and practice (use of the knowledge obtained in the real world, or “street smarts”). When students observe me working they often ask questions like “You made that look SO easy!” or “Did you learn that when you were in school?” but the fact of the matter is that this level of education provides you with the tip of the iceberg. To find the mountain beneath the waves, you have to do some diving on your own!

Some of my basic tips for developing some of the skills you need to use everyday in this profession:

Adjusting:

• Study class notes, books, manuals, videos, whatever you can get your hands on from reliable sources
• Review the fundamentals
• Get out your atlas of anatomy and your neurology textbook and understand the biomechanics and neurology of what you are trying to achieve… be able to visualize what you are doing and why
• Practice daily with a speeder board 
• Palpate as many people, especially with a variety of body styles, as you can get your hands on
• Adjust as many people in the clinic as you can (don’t “dump” your students just because you’re done with your “student numbers”)… every patient is “practice” and you will learn something every time you help somebody

Examinations:

• Basically the same advice applies… read the textbook, notes, find videos (there are a lot free out there), etc
• Understand anatomically and physiologically what the exam procedure does and how it works
• Perform the procedure on as many people as possible, whether you “need the numbers” or not… this is the only way to learn the difference between positive and negative findings

History and Patient Communication:

• Learn how to be a good listener and let your patients talk while guiding them to keep them focused
• Use shorthand and learn to take accurate, detailed, but quick notes
• Listen to clinicians talk to patients and how they go about getting information
• Talk to people!

Business Management:

• This one is a little tougher to do in school, but anything you can do to learn about policies and procedures, even working part time as a CA or in the office of a real practice, will pay major dividends down the road

Always keep in mind that your skill is directly related to the amount of work you put into your courses as well as your diligence in practicing what you are learning. You cannot expect your teachers to develop skill for you… only you can do that for yourself with lots of hard work.

Understanding Insurance Codes

In the clinic, you use insurance codes on every visit, but you may not know it. Before you read on, if you get nothing out of this article than “Buy and use a ChiroCode Deskbook,” then I have accomplished my mission! Seriously, it’s the best book for coding and, more importantly, understanding the codes and how to use them, for chiropractors today. And the book is only $99. I think some state associations have a deal with ChiroCode and make them available once a year at a discount. I think I bought mine through the Michigan Chiropractic Society (now the Michigan Association of Chiropractors) for $65 when I went into practice.

In any case, there is a lot more to insurance codes than memorizing which one to use when. In fact, I highly recommend you do not memorize codes. Your memory will vary depending on the situation and your concentration, while a chart or list will not, so rely on a chart or code book and leave your memory to other things that won’t land you in a heap of trouble and a fine if you transpose a number or accidentally use the wrong codes. Insurance companies don’t believe in accidents!

The two types of codes you use in the clinic are ICD-9 and CPT®. ICD-9 (International Statistical Classification of Diseases and Related Health Problems) codes are codes that are up to six digits in length and they describe a disease or pathological process… these are your diagnosis codes. CPT® (Current Procedural Terminology) codes are maintained by the American Medical Association and are a registered trademark of that association. CPT® codes are procedural codes that tell an insurance company what procedure was performed.

For example, you could diagnose a patient with low back pain due to subluxation of the lumbar spine. Using your trusty code book, you would use the ICD-9 code for “lumbago,” which is the same as “lumbalgia,” which is low back pain. That diagnosis code is 724.2. The code for subluxation of the lumbar spine is 739.3. Now, let’s say you decide to adjust the patient and also do 15 minutes of ART® muscle work. You would use the CPT® code 98940 for “chiropractic manipulation, 1-2 regions” since you adjusted the lumbar spine and also the code 97140 for the 15 minutes of ART® you provided. In fact, in order to let the insurance company know that the ART® service was separate and distinct from soft tissue work that would associated with a normal adjustment, you would also apply the “-59″ modifier to the soft tissue code, so it would be reported fully as “97140-59.”

When the insurance company receives your claim form, then, they would know what the patient’s problem was and what you did to help it. This system of using codes for diagnosis and treatment is a way of standardizing the “language” of health care into a system that is universal in the United States. Otherwise it could get very confusing and insurance would be an even bigger mess than it is now! 

Insurance companies keep complicated statistics so they know the typical trends in how these codes are used. In our above example, their super databases know that, typically, there are a half dozen or so things a chiropractor may do to help a patient with low back pain, whether it is the adjustment, soft tissue work, massage, rehab procedures, orthotics, physiotherapeutics, etc. In other words, if you decide to bill for smoking cessation and group diabetic counseling for the LBP, the claim will be “flagged” and you will probably not get paid, as you are falling outside of the norms of clinical practice.

A subset of coding that will be addressed in another article is the use of Evaluation and Management (E/M) codes. These are part of the CPT® structure, but they describe the codes used for exams and various ways you consult and manage your patients. Choosing appropriate E/M codes is quite complicated and there are specific rules for it, so the ChiroCode Deskbook is worth its weight in gold as I have never seen a better description of how these codes work, why, and how to appropriately use them anywhere else.

X-Rays: Yes, No, Maybe?

We recently started enforcing (again) the decision that interns need to have the radiology criteria forms filled out along with the radiology report, even when you aren’t going to take x-rays. Needless to say, having to have these extra papers is not super-popular with students, but there really is a reason for it, and a very important one at that.

When you are in practice, every decision to, or not to, do something is a clinical decision based, hopefully, on reasoning, experience and evidence. When it comes to x-rays, you have to take these decisions even more seriously than you do with any other clinical decision because x-rays utilize ionizing radiation that is potentially harmful to a patient. As such, you want to have a pretty good reason for taking x-rays of a patient, of which there are many.

Just as you base your decision to take an x-ray series on good reasoning, there should be ample reason for why not to take an x-ray. While it’s true that x-rays use ionizing radiation, and so you shouldn’t use them willy nilly, the more potentially harmful aspect of x-rays is missing something on the film because of poor reading or poor film quality, or missing something altogether because you didn’t take the x-ray in the first place. 

When I started practice in Michigan in 2000, about an hour north of me a doctor had injured a patient because he had a patient complaining of midback pain and he decided not to take an x-ray. It turns out the patient had metastatic cancer that had spread to the vertebral column, and the adjustment the doctor did badly injured the patient. That said, the doctor followed the standard of care and really didn’t have much reason to take an x-ray of this patient for the complaint and signs/symptoms he presented with.

The decision not to take an x-ray is every bit as important as the one to take an x-ray, so it should be documented, and the reasoning upon which the decision not to take an x-ray is based upon should also be proven, which is why the x-ray criteria sheets are important even when you don’t want to take an x-ray. In fact, honestly, in my opinion, this documentation is more important when you don’t take an x-ray than when you do, from a medicolegal perspective.

Cell Phone Etiquette

If you ask any doctor what one of their pet peeves about patient behavior is, high on the list will be when a patient’s cell phone rings and they answer it. This causes you to sit there looking dumb, and it wastes your time. Doctors feel disrespected when they are interrupted by a patient’s phone call. Think about when it happens to you in the clinic. It may not seem like such a big deal, but trust me, when you’re working for a living having your patient talk to their bud about that funny thing they saw on the Blue Collar Comedy Tour last night is going to make you lose your patience really quickly.

Now, think about what a patient feels when you answer your phone during one of your visits? How professional does it look when you’re texting someone while you escort your patient to the checkout counter? Answering your phone while you’re with a patient sends such a bad message to your patient it’s hard to even describe fully the negative effects entirely.

Your patients come to you because they need your care. Giving good care requires you to be attentive to your patient. Giving good care requires focus and mindfulness. Answering your phone during an office visit is the absolutely most blatant signal you can give to your patient to tell them “I don’t really care about you.” It may sound harsh, but it’s true.

Does your dentist answer the phone when you’re getting a filling done? Does your MD text his buds while he’s taking your history? Does your chiropractor talk on the phone during the middle of adjusting you? Of course not! So, why do you do it to your patients?

Short of a family emergency or crisis, there is no reason for you to have your phone even turned on in the clinic. You aren’t that busy. You aren’t an OBGYN on call or a 7th year cardiothoracic resident working 90+ hour weeks. You can wait a few minutes to check your messages and return calls after you’re done with your patient. Your voicemail message should say “This is So and So, I’m either with a patient or in class, so please leave a message and I’ll get back to you as soon as I can. Thanks!” You’re not going to lose a patient or a visit because you had to wait a while to return a phone call.

The #1 complaint patients have when they leave a doctor is “I didn’t feel like they listened to me” or variations of that theme like, “I felt like a number there” or “They seemed to care a lot more about my insurance than they did me.”

How do you think they feel when you can’t even be bothered to talk to them as you escort them out of the clinic? How do you think they feel when you interrupt their history, or their treatment, so you can talk to a friend or another patient on the phone?

Do yourself a favor and turn your phone off when you are seeing patients. You won’t believe how more focused you will feel. Your patient will perceive a better connection, too. A lot of healthcare isn’t about what you do, but how you do it, who you are as a person and how you connect with your patients. If your plastic phone is more important to you than the real person who is trusting their health in your hands, you need to sit down and reassess your priorities and, especially, consider whether this profession is right for you. It’s all about the patient, not you, and certainly not your phone.

Speeder Board: A Guaranteed Way to Improve Your Adjusting

A “speeder board” is a portable drop piece manufactured by Thuli Tables, Inc. When I was a student, buying this piece of equipment was not an option. We needed it in every adjusting class and I can honestly say that I still practice with it today! In school, this drop piece is a great way to start training the mechanics of the adjustments you are learning about. A speeder board costs anywhere from $50-$60 and is available at the bookstore or directly from Thuli at http://www.thulitables.com.

The speeder board is useful for more than just training, though, too. It is small enough to be easily portable, and it is great for extremity adjustments, so this is a one-time investment you can use throughout your professional career as a chiropractor. The speeder board features a straight P-A drop and has a large amount of tension adjustment so you can use it for a variety of body types and applications, as well as to practice different types of adjustments.

You can purchase a Thuli speeder board with an optional insert that mimics the feel of a spinous process or atlas transverse process. When practicing with the speeder board, you can place it on a table and do single hand, double thenar, Meric arch, Carver bridge, Palmer Upper Cervical and any other Diversified or Gonstead hand setups and practice your thrusts. Adjusting is a complex manual skill involving simultaneous contraction of your triceps and anconeus, as well as the pectoralis muscles. Of course, their agonists and antagonists need to be in the picture, too. When you first start learning adjusting your thrusts are weak and slow, so you compensate by adding weight (body drop or just bouncing into your patient). These methods work, but they are uncomfortable to the patient, hard on you, and are totally unnecessary. Adjusting is an art that requires speed and finesse, not brute strength.

Holding the speeder board in one hand, you can practice Gonstead cervical chair adjusting, where speed is essential. The board is perfectly sized for you to mimic C1-C7 adjustments and the insert can help you develop the feel of what a Gonstead spinous process contact feels like. When you practice your Gonstead thrusts this way, you not only train your adjusting hand, but you also get a very realistic feel for how to properly stabilize the patient. Gonstead adjusting requires good stabilization and isolation of as much of your adjusting force to the one segment you are attempting to move. Speeder board drills are perfect for developing this muscle memory.

I suggest spending 10-15 minutes with a speeder board doing drills every day when you are a student. When you are busy in practice the necessity of speeder board drills diminishes, but it is still good to practice basic skills whenever possible. I still use my speeder board and do drills on a weekly basis, and daily I practice my old Palmer Upper Cervical/Toggle Recoil thrusts on my tables at home, even though I stay busy with my own patients. You can never overdo it when it comes to the fundamentals.

5 Books I Couldn’t Live Without

Go into any clinician’s office (or the offices of most chiropractors who have been in practice for more than a few years) and you’ll see the same thing in all of them: books, and usually, lots of them. Why do we have so many books? I had a student jokingly accuse me of just having them because they “make me look smart,” implying they were all eye candy for my bookshelf. He changed his mind when I handed him a few random selections and he saw notes in the margins, broken spines (no pun intended) and bookmarks ad nauseum. Yes, I’ve read all my books, most of them many times. Hell, I even bought books when I was a student, when they weren’t even required, and for the full price in the bookstore!!! Oh my gosh!!! Can you imagine?!

It startles me to find out how many students don’t buy books for classes and graduate from school with nothing more than the professor’s notes from their classes. Health care information is a lot of gray and often times not very much black or white. Every orthopedics textbook describes a different way to perform or interpret tests, for example. Neurology is constantly being updated and added to. There are always new technique books, anatomy books, soft tissue, diagnosis, herbal and nutritional and radiology books, and the list goes on and on.

Reading a book gives you more information than you had before. More importantly, they usually give you a deeper level of knowledge on a subject you may already know something about. They challenge what you know and what you think you know. They are resources you can pull off the shelf whenever you need them, and you can trust them a heck of a lot more than the information Google finds for you. They are also great patient education resources, allowing you to copy material or sit and read a little with the patient when they need an explanation about something. They have illustrations and photos that speak a thousand words, etc etc.

That said, there are five books I can say I couldn’t live without in practice. I don’t even have to think about them. They are the most beat up, most written in, most bookmarked volumes on my shelf, and I think they are indispensable in any chiropractic office. In no particular order:

Anatomy - Clemente

 

 

• A Regional Atlas of the Human Body by Clemente – there is no shortage of wonderful anatomy books on the market, but Clemente is one of the “classics.” So is Netter’s book, and of course, the British version of Gray’s Anatomy (it was a book before it was a TV show). I learn something new or gain some insight every time I open this book. Your adjusting will be better when you understand what you’re doing in an anatomical sense, your muscle work will be better, your understanding of biomechanics and, therefore, what is wrong with your patients will improve leaps and bounds when you regularly use an atlas of anatomy.

Orthopedic Physical Assessment - Magee

 

• Orthopedic Physical Assessment by Magee - just like anatomy books, there are a dozen great orthopedic textbooks on the market. I own Evans’ orthopedic textbook, too. I use them both all the time, but if I could only have one, this would be it. Nicely written and laid out, great illustrations, well organized, good photos… just an all around gem of a book and I use it on an almost daily basis to either reference something, refresh something I already have learned, or to show something to a patient or student.

Radiology - Marchiori

 

• Clinical Imaging with Skeletal, Chest and Abdomen Pattern Differentials by Marchiori – Dr. Dennis Marchiori was one of my radiology professors when I was in school at Palmer. Over and above being a great guy, this is an unbelievably great book. Excellent visuals, very practical, and the pattern differential organization makes finding what you think you see on the x-ray easy in the book. A lot of people are partial to Yochum and Rowe’s radiology texts, which are also great, but again, I think every DC and student needs this on their shelf. I use my first edition every single day.

Merck Manual

 

• The Merck Manual of Diagnosis and Therapy – this small, thick book is indispensable in a chiropractic office. Every disease, syndrome and zebra (as well as the common stuff!) is in here, summarized very clearly and succinctly so you can know what you need to know about a health condition in a minute or two. This is a great source of information and I don’t know what I would have done in private practice without it.

ChiroCode Desk Book

• ChiroCode Deskbook – Last, but certainly not least, is this gem of a book. The included CD will calculate all the Medicare fees and local regional modifiers so you can generate a ballpark reasonable fee for each service. It tells you the ins and outs of billing Work Comp, auto/PI, Medicare, Medicaid and private insurance. It takes the mystery out of Evaluation and Management coding. It has all the procedure and diagnosis codes you will ever use and describes them in plain language so you are selecting the correct code. It helps you document better and allows you to avoid common pitfalls in billing and coding. This book is worth ten times its weight in gold, honestly. I used it more than any book in my practice and it should be a required text in any chiropractic business class. You cannot practice without this book, in my opinion! 

19-NC… What It Means and How to Use it in the Real World

By now you must have noticed the code “19-NC” cropping up on your service slips pretty frequently. As you were told in class, this is a new internal code being used in the clinic to track your use of soft tissue work that doesn’t qualify for a full 97124 (massage) or 97140 (manual therapy) because you didn’t do it for a long enough time. States are starting to require some physiotherapy hours for graduates seeking a license there (California comes to mind), so the “19-NC’s” add up to help out with these hours.

Keep in mind that 19-NC is an internal code used in the college clinic system only. It is not a real procedural (CPT) code, so once you walk across the stage at graduation, forget it ever existed! In the real world, soft tissue work falls under one of two codes:

• 97124 (massage) – more or less what it sounds like… the patient is passive and the doctor (or better yet, your employed massage therapist) performs a service to increase tissue relaxation and promote circulation. This code encompasses superficial, effleurage, petrissage, percussion, pressure point (acupressure), trigger point and deep-tissue techniques. Using a mechanical massager like a Genie-Rub or G5 would qualify for this code, too. 
• 97140 (manual therapy) – this code includes manual traction, manual lymphatic drainage, joint mobilization, myofascial release and non-chiropractic manipulation. The main distinction between the techniques that fall under this code and 97124 is specificity. Massage has general benefits and is usually applied to a fairly large area, versus manual therapy that is usually applied to a small area or specific muscle with the intent of reducing fibrous adhesions or something similar. Your Graston and PNF (ART-like) stretching would fall into this category.

The other key to using these codes is that they are time-dependent and require constant attendance. Using one of these codes tells an insurance company that you did one unit, or 15 minutes, of this type of work. So, when you use these codes in the clinic, you are telling us you did these procedures for 15 minutes, too, which very few interns really do. Rather than not getting credit for the work you did do, the clinic administration uses “19-NC” to show you did the work, but not enough to be considered a full 15-minute unit.

In the real world, you use a modifier to the code to tell the insurance company the same thing. the modifier “-52″ is used for “reduced service.” Let’s say you spend 5 minutes with a patient doing Graston on their Iliotibial Band. You can’t bill this as a full 97140 because you didn’t do it for 15 minutes, but you don’t want to not bill for it at all because you need to get paid for what you do. So, you would code this service as 97140-52, which tells the insurance company you did this type of work, but not enough to bill for a full unit. When the insurance company reimburses you, they will pay at less than the regular amount for a full unit of this code, so it works out as it should. On the other hand, let’s say your massage therapist performs 30 minutes of massage on a patient, you would bill two units of 97124 and get paid whatever the approved reimbursement is, times two.

Things get a little more complicated in billing for these codes for two reasons: different people define “time” in different ways, and insurance companies get paranoid when you start lumping a lot of 97140, 97124 and 9894x’s (adjustment codes) together on the same visit. In general, if you perform a 97140 or 97124 on a patient the same day as an adjustment, you need to use another modifier, -59. This tells the insurance company that the service was separate and distinct from your other services. Typically, even then, insurance companies will not pay for both a soft tissue and adjustment service in the same region on the same day, so you need to be aware of this and charge your patients accordingly. Every insurance company is different in this regard, which is why you need to verify insurance carefully and also attend your state-sponsored “Billing 101″ and “New Doctor” seminars.

As far as the interpretation of time goes, when I was in private practice my goal was to keep everything above the table and not get “fancy” or “creative” with how I did things. Worked well for me. To me, 15 minutes was 15 minutes. My two massage therapists worked in increments of 15 minutes. According to most billing experts, however, the time it takes to determine the need to administer these codes is also part of the 15 minute unit, so the history and exam you or a massage therapist would do before rendering one of these codes technically counts as part of the time. I don’t know if that’s true or untrue, so I’ll let you make that decision for yourself. Furthermore, it is widely believed that the services are to be billed for the “closest time to that unit,” so “one unit” really means anything from 8-22 minutes, “two units” really means 23-38 minutes, and so on. Again, I don’t know how true this is.

So, now you know what 19-NC means and how you will apply the same idea to real CPT codes in your practice with the real modifiers that go along with them.