How Will the Mercy Guidelines Affect the Chiropractic Profession?

An interesting event recently occurred in Louisiana between an insurance company and a chiropractor utilizing a muscle testing devise. This story proves to be a perfect example of the kind of benefits and the ultimate responsibilities that the Mercy Center Conference Guidelines bring to the chiropractic profession.

A chiropractor (we'll call "Dr. Jones") used a muscle testing devise on a patient who had been recently injured with an acute soft tissue injury to the cervical spine. Upon submitting the appropriate bills to the third party insurance company (we'll call "Big Insurance"), the use of muscle testing devices was questioned by Big Insurance. The following were the concerns of Big Insurance:

"Procedure Code 97752 (muscle testing) is in our opinion not medically nor chiropractically reasonable or necessary since manual muscle testing is a part of every chiropractic examination, the medical necessity of this additional, costly procedure appears doubtful. In addition, as we understand as of 5-8-91, there have been no published, independent studies documenting the usefulness, effectiveness, or reproducibility of the comparative muscle tester.

"Therefore, we questioned that charge as reasonable or necessary for the injuries of cervical dorsal syndrome, code 352.2, hyperextension or hyperflexion injury to the neck, code 847.0, or cranial neuralgia, headaches syndrome, code 355.9."

Ultimately, both Dr. Jones and Big Insurance agreed to binding arbitration. Fortunately, the Mercy Center Conference Guidelines were able to play a significant role in the outcome of this very important case. The outcome of this case was critical, for it would probably determine the future of muscle testing device usage in Louisiana and possibly set a precedent for the entire country.

The arbitrator stated in his report:

"Many factors must play a role in resolving the questions that you raise. My opinion will be based on all information that I have available to me and will not be limited to only one criterion. Therefore, I will attempt to present a discussion of your questions, with this attitude, and then express the conclusion and/or opinion that you have requested. The first part of the discussion will follow the format of your letter by addressing each of the questions that you have posed.

"In your letter you (Big Insurance) questioned medical necessity based on three opinions. They are as follows:

1) Contention of Big Insurance:

"...manual muscle testing is a part of every chiropractic examination, the medical necessity of this additional, costly procedure appears doubtful."

Arbitrator's Response:

"Although, it seems unreasonable on the surface to have a physician perform some type of test manually and then follow up with a more sophisticated instrument for which an additional charge is levied, you will find, it is often a standard practice procedure. The initial test determines the presence of a problem (in this case muscle weakness) and the follow-up test quantifies the condition in a much more measurable manner. This aids the physician in monitoring progress of the patient's condition. Examples of this same type of practice would include tests for the presence of thoracic outlet syndrome, EMGs, ECGs, and EKGs to mention a few."

2) Contention of Big Insurance:

"...we understand as of 5-9-91, there have been no published, independent studies documenting the usefulness, effectiveness, or reproducibility of the comparative muscle tester."

Arbitrator's Response:

"Your statement appears correct. My investigation of the literature has not revealed any research that has been _independently_ published regarding this piece of equipment. As you probably know, the manufacturers have done their own research and have published their conclusions. This could be considered biased research; however, there are several points which need to be made regarding the acceptance and use of this equipment by health care providers of all types.

A) "The latest book of CPT codes (1992) published by the AMA lists this code as an acceptable procedure. As you stated in your letter, the code number of this procedure is 97752; and, the manual states on page 559..."Muscle testing with torque curves during isometric and isokinetic exercise, mechanized or computerized evaluation with printout.

B) "Within the chiropractic profession our national associations in conjunction with our colleges and research organizations are developing 'practice parameters' that I'm sure you will agree, are badly needed. As a part of the process, a week long conference was held at the Mercy Center in San Francisco, California, in January of this year, which is the culmination of two year's work. A preliminary draft of these proceedings has been used by (Dr. Jones) to support his position in this matter. In the section discussing the use of muscle testing instruments the following is stated:

'Diagnostic assessment naturally falls into three categories:

1) preventative evaluation (as in employee job-matching); 2) post-injury evaluation; and 3) outcome monitoring following treatment.

Significant clinical information can be obtained toward these objectives, but careless interpretation of test data can result in inappropriate clinical decisions. Acute disorders are a contraindication to strength test protocols. The average discrepancy between symmetrical muscle groups for healthy populations has been reported as much as 12%. When evaluating an individual's performance, differences of 20% or more may be needed to discriminate abnormalities.'

"The statements made in this section are supported by a list of published studies using these types of muscle testers in patient and employee evaluations. Although none of the published papers test the reliability of the instruments used, the results (of these devices) are repeatedly used to determine normal values and deviations from normal.

C) "Finally, the Chiropractic Association of Louisiana has published The Chiropractic Manual for Insurance Claims Personnel, (2nd edition) which has also been adopted by the Louisiana Board of Chiropractic Examiners as the official guide for their peer review committee. On page IV-4 of this manual, "Manual and electronic muscle testing" is listed under the heading "Routine Examinations."

3) Contention of Big Insurance:

"... we questioned that charge as reasonable or necessary for the injuries of cervical dorsal syndrome, code 352.2, hyperextension or hyperflexion injury to the neck, code 847.0, or cranial neuralgia, headaches syndrome, code 355.9."

Big Insurance Response:

"It would appear that any condition, which might result in muscular weakness and that weakness has been confirmed by routine clinical means, would be the only criteria (clinical findings) necessary to demonstrate the need to utilize this type of muscle tester. More specifically the Mercy Center Report indicates that it is appropriate in 'post-injury evaluation and outcome monitoring following treatment.'

"Finally, I am of the opinion that, (Dr. Jones) has sufficiently met the requirements to prove the medical necessity of utilizing a 'Cervical Electrical Muscle Tester' as a valid instrument; however, in this particular case there is one additional area of discussion which must be dealt with before a final conclusion can be rendered. The question that must be answered... Is the utilization of the manual tester 'appropriate' in this particular case? Since the treatment record indicates that the patient who was evaluated with the muscle tester had sustained an acute soft tissue injury to the cervical spine only 11 days prior to the test being performed, and since the Mercy Center Report states 'Acute disorders are a contraindication to strength test protocols' the conclusion must follow that utilization of a muscle testing device in this case is inappropriate because of the timing of its use being in the acute post-injury phase of care."

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The decision of the arbitrator has accomplished two things.

First, after reviewing the Mercy Center Guidelines, the arbitrator found that Dr. Jones "sufficiently met the requirements to prove the medical necessity of utilizing a 'Cervical Electrical Muscle Tester' as a valid instrument." This is a very important victory. The chiropractic profession must be able to continue to utilize the diagnostic and therapeutic equipment that is of benefit to our patients.

Secondly, even though the use of a muscle testing device was well established in the general terms of medical necessity and validity, Dr. Jones' specific utilization of the device was still required to meet the criteria of "appropriate." Again, the Mercy Center Guidelines spoke to this issue and found the utilization "inappropriate."

In this case, as in others, the Mercy Center Guidelines appear to be leveling the playing field and adding certainty. These are two important benefits that will ultimately serve the public as well as the profession.