The Importance of Staying in Touch

I realized recently why things are always so slow to start up after the trimester break. It really hit home today when a patient complained that he had called his new intern 3-4 times in a few days’ time, leaving messages every time, and the intern never bothered to call back.

I am the first to know that we all have personal lives, but your commitment as an intern, and soon as a doctor, is to take care of people. That doesn’t always happen at a time that is convenient for you, and you are often asked to make sacrifices to take care of others. This is the reality of being a doctor of any type. Calling a patient back is hardly a sacrifice… this is a person who wants to come into the clinic weekly, and his intern is too busy or too preoccupied to return a phone call? In the real world this is a patient who would be switching to another practice.

Anyway, I started thinking about the trimester break. Senior interns start checking out of clinic a couple weeks before finals. Junior interns are still worrying about finals, and so they think “Well, I’ll call this patient next week…” Well, think again. Finals goes on for a couple weeks, then there is the trimester break. I’m sure a lot of interns take “one last vacation” or veg out a little. Coupled with the reduced clinic schedule, all of a sudden we have a recipe for disaster…. Senior interns start turning patients over to junior interns a week or two before finals, the juniors are studying and worried about finals and then check out mentally for the break, thinking “I’ll get that patient in soon when school starts back up…” and lo and behold, 4-5 weeks have gone by without any communication with these patients.

Not only is this inconsiderate of these patients, who need and want your care, but it is very poor patient management. Like I already mentioned, in the “real world” every single one of these patients would have thrown the towel in with you and found a new doctor to take care of them. I had close to 25 chiropractic offices in the town of 38,000 I practiced in. It would be effortless to find a new doctor who could see a patient the same day. You better believe I stayed in good communication with patients!

Put good habits into place now. Call your patients and schedule them as soon as they are transferred to you. Schedule time for a patient transfer evaluation and fill it out properly by spending some time with the patient’s file. This is what you will be doing everyday for the rest of your career if you plan on practicing, so you should get comfortable with this now, as well as juggling exams, personal life, finances, etc. Life doesn’t get any less hectic in practice.

How to Use Soft-Tissue Procedure Codes

We visited this topic in another post, concerning the use of the internal clinic code 19-NC, but this is a more in-depth look at how and when to properly use soft tissue codes. This area gets a lot of chiropractors into trouble in practice, so start implementing this information in the clinic and you’ll be ready to continue good habits out into your own practice! Using the various codes available for soft-tissue work seems pretty straightforward, but I suspect that doctors and students are not given the best information at practice-building or technique seminars concerning how to use these codes.

 

Massage - 97124

Massage – 97124:

The massage code is separate and distinct from the other manual therapy and adjusting procedures you would be performing on a given day. Massage is used for soft-tissue work that is totally passive in nature, requiring no movement or work from the patient. The goal of massage is to relax tissues and promote circulation. Massage may be used to reduce edema or swelling, calm a muscle spasm, restore muscle function and improve joint range of motion. The procedures included in the 97124 massage code are effleurage, petrissage, percussion, superficial (Swedish) massage, pressure point (acupressure, trigger point, Nimmo, etc) work that is passive (as opposed to something like ART or Strain Counterstrain, as we’ll see in a moment) and the use of tools to accomplish the same thing, such as a “Thumper,” G5 massager, etc. Massage is generally given to a large area of the body and crosses multiple types of tissue in a general way (i.e. not making much of a distinction between muscle, tendon, ligament, etc. In some cases Graston or other instrument-assisted soft-tissue techniques may be considered a 97124 code, but usually it falls under another code described below. Of course, massage requires a doctor or therapist to be in constant contact with the patient.

Trigger Points - 97124

This code is billed in 15-minutes units. One unit of massage would be appropriate for 8-22 minutes of application. Two units would be used for 23-37 minutes of application, etc.

Manual Therapy – 97140:

This code encompasses a wide variety of services commonly performed by chiropractors, including manual traction, non-chiropractic manipulation (mobilization, for example), myofascial release, joint mobilization and lymphatic drainage. Techniques such as Strain Counterstrain, ART (MFR), muscle energy techniques and Graston would be most appropriately billed using this code.

As important distinction between manual therapy and massage is the specificity. Manual therapy is generally specific to a single tissue or muscle/joint. Massage, on the other hand, is more general in nature without much distinction to specific tissue types in the delivery of the therapy. For example, massage may be given to the entire back, whereas Graston would be isolated to the right upper trapezius.

 

Graston Technique - 97140

The intent of manual therapy is generally to work on fibrotic tissue and adhesions. The goal is to restore function to the target tissue. Manual therapy may be passive (from the patient’s perspective), such as in the case of most Graston techniques, or active, as in Strain Counterstrain or ART. Notes should always specify the specific area and time that was treated, as well as the technique used and any outcomes (improved ROM, improved tissue pliability, muscle function, etc). 

 

 

Neuromuscular Re-Education (97112):

This is an often misunderstood and improperly used code. It is used when re-training a body part to perform a task it was previously able to do. Physical and occupational therapists typically use this code for post-surgery, stroke or injury patients. It involves exercises that retrain the body part to do what it is commonly needed to do (standing, walking, flexing, extending, grip, etc). Balance, coordination, proprioception and posture may be a factor of this code, too. Chiropractors rarely engage in true neuromuscular re-education activities. Some types of postural rehabilitation and the use of wobble boards, for example, would be allowable under 97112, but the soft-tissue techniques mentioned above are never to be used with this code, contrary to what seminars may tell you!

Taking Time To Celebrate

This is for those students who are graduating in a few days… remember to celebrate your achievement! Not just partying, etc, but really take time to reflect on where you have been in the past few years… 7-8 years of college, moving, working hard, ups and downs… A lot of people go, go, go, but forget to pause and pat themselves on the back for their achievement.

Celebrate, but don't light yourself on fire!

Now, the REAL work and learning begin! lol Seriously, it does, but seriously, take a little time to do something for yourself and your family, loved ones, friends, etc. You deserve it, and so do they for putting up with you! Remember throughout life to stop and smell the roses from time to time… take stock of where you’ve been and what you’ve done, celebrate it, and move on toward creating and meeting new goals. Most importantly, do worthwhile things well and with pride and you’ll be a success!

The Art of the Patient Transfer Evaluation

OK, well, maybe “art” is pushing it a little bit, but since we introduced the Patient Transfer Evaluation a year ago, the “art” of doing it properly (and getting the most out of it) has been lost, so this article is timely if nothing else.

The purpose of the Patient Transfer Evaluation (PTE) is twofold: to familiarize yourself with the case of a patient who has just been transferred to you from another intern, and to evaluate the patient’s progress. Unfortunately, interns always wait to do the entire PTE when the patient is in the room, but in fact, about 1/2 or more of the PTE is supposed to be done before the patient’s visit. Most of the PTE is you going through the file looking at the information… past complaints, positive examination findings, current progress, etc. 

A PTE should take no longer than a “blue soap” note, when done properly. The part that is done when the patient is in the room is simply the updated evaluation procedures. When done properly, the PTE should only add a handful of minutes to your regular visit, and you get CMR credit (once you do the CMR, of course) from it. 

Start spending more time with transferred patients’ files so you can learn about their problems, what is working (or isn’t working) in their care, and can pick up right where the past intern left off, or move in a new direction as may be necessary. It makes you look a lot more professional to the patient, you’ll save time, and your care of the patient will be much better.