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Chiropractic Use of CPT Evaluation & Management Codes

Dear Editor:

In the April 8, 2004 issue of Dynamic Chiropractic, K. Jeffrey Miller, DC, opines that current procedural terminology (CPT) codes for evaluation and management of new patients (99201-99205) as well as established patients (99211-99215) are problematic for the chiropractic practitioner.

Dr. Miller concludes, "Chiropractors are forced to use both allopathic procedures and chiropractic procedures in order to meet coding requirement and treat patients." Dr. Miller also concludes, "Consequently, chiropractic practitioners must work harder than allopathic practitioners to meet coding requirements. Adding insult to injury, Doctors of chiropractic typically receive lower reimbursement for evaluation and management procedures, despite their extra effort." Dr. Miller goes on to "propose" revision of evaluation/management services for chiropractic evaluation exclusively.

The American Chiropractic Association (ACA) does not support this analysis or the recommendations to pursue a line of nonphysi-cian evaluation/management code development for chiropractic. The ACA has been involved in the CPT process since 1995. The ACA currently holds a seat on the CPT Healthcare Professionals Advisory Committee for CPT Codes and the Relative Value Update Committee (RUC). The ACA has been instrumental in researching, documenting and evaluating the work that chiropractors perform, both in evaluation and treatment services. The ACA has been instrumental in assuring that all physicians, including DCs, receive the same general relative work value for providing the same service.

The ACA began publishing Recommendations for Describing Chiropractic Services using CPT in 1997. The ACA publishes vignettes that are intended to give the chiropractic practitioner examples of clinical situations and appropriate use of E/M codes in conjunction with chiropractic manipulative treatment services. Moreover, the ACA continues to be involved in the research and relative value study process that is ongoing with evaluation and procedure codes.

Suggestions that chiropractic practitioners utilize a "proposed" methodology that is not equivalent to current evaluation/management framework gives support to other specialties, and claims payers, who suggest that chiropractors are not entitled to the use of evaluation/management codes. Standards for doctor of chiropractic programs currently require clinical competencies that are of a complexity that is physician-level, and current evaluation/management codes should be utilized by doctors of chiropractic to report the level of evaluation that they perform. Suggestions of an alternate system are not supported and are not endorsed by the American Chiropractic Association.

The American Chiropractic Association
Arlington, Virginia

Dear Editor:

I've read with interest every column you and your late father ever wrote, and I must say, you've both been bastions of the faith, especially in getting us to see ourselves. I graduated in the late 1960s and thought the profession was still in fledgling state then. I can tell you of the horrors of attending chiropractic school in a small utility building, much too hot in the St. Louis summers and very cold in the indescribably frigid winters. Some of my old notes are illegible, mostly due to being transcribed while wearing gloves. I've practiced 35 years, waiting for our glorious profession to come of age, grow up and get its act straightened out. I can't tell you the number of the people I've talked to over the years who had the ACA and ICA together, went to bed and found them as far apart as ever the next morning.

We are living in a wonderful time, with the greatest profession the world has ever seen at our fingertips. In true chiropractic fashion, we choose to emulate those who came before us, and keep the feud going. We can hide behind every idealistic excuse we choose, but the bottom line is, we aren't as busy and successful as we would like to be and abhor anyone else who might be approaching what we would imagine ourselves to be, in our wildest dreams. Anyone with a new car, country club membership, new five-bedroom house, or other luxuries is suspected of being a fraud or shyster. When are we going to wake up? When chiropractic is stolen from us and practiced as physical medicine or physical therapy? You have to consider that the public doesn't care what it is, so long as they get relief. If it looks like a duck and quacks like a duck, it must be a duck. The public doesn't have a lot of time for the sermons or ramblings of "chiropriests." How long will it be until we either wake up, or end up in the back of the health care bus where we used to be (or under it, for that matter)?

Thos. L. Smith, DC
Wooster, Ohio

Dear Editor:

One of my biggest pet peeves is the "Dr. ... DC" title many chiropractors use in advertising, business cards, articles, etc. When we refer to ourselves as Dr. Jones, DC, we sound insecure, egotistical, and somewhat ridiculous. Yet so many DCs do it all the time, to a point where it seems almost unique to our profession. You rarely see MDs, DOs, and dentists doing this. And like them, we are doctors, not doctor-doctors. Quite frankly, I know I am a doctor, my patients know I am a doctor, and most of the world knows chiropractors are doctors.

I am not the only chiropractor who feels this way. Dr. Larry Markson gave examples of silly Yellow Page ads recently at a seminar, and examples of doctor-doctor were near the top of his list.

Another thing many chiropractors feel the need to do is let the public know that they have an undergraduate degree in addition to their doctorate, e.g., Dr. Smith, BS, DC. It is assumed by the general public that we earned our BS or BA prior to attending chiropractic college. (I know most chiropractic schools do not require it - another pet peeve of mine, but I won't go there). It is certainly appropriate to state MS, DC or PhD, DC, etc. as these are graduate degrees. Let's face it, BS (or BA), DC looks pretty silly to the general public and downright moronic to our skeptics and scrutinizers, who, unfortunately, are like hungry sharks circling our waters for unprofessionalism in our ads and journals. This too (BS, DC) is something rather unique to our profession.

Are we so insecure about ourselves as chiropractors that we feel compelled to do these things? We are not second-rate doctors, so why do so many of us choose these unprofessional modes of self-titling? Not only should we be proud to be chiropractors; we should also be more than satisfied to refer to ourselves as Dr. John Smith or Mary Jones, DC.

Thank you for allowing me to express my long-standing opinion.

Dr. Mark D. Nierenberg, BA, BS, DC

Oops! I mean:

Mark D. Nierenberg, DC, DABCO
Bridgewater, New Jersey

Dear Editor:

I thoroughly agree with Dr. Seaman's assertion that the chiropractic subluxation results in nociceptive excitation [see April 22, 2004 DC: "Subluxation Complex and Nerve Interference, Part II"]. In fact I first encountered that concept in D.D. Palmer's The Chiropractor (1914, p. 48): "The displaced bones of any luxated joint may impinge upon a nerve, or by their displacement cause a nerve to be stretched, thereby creating inflammation." And in reference to people who were writing about chiropractic at that time: "These writers now use the word 'impingement' instead of 'pinch,' seeing the founder of chiropractic makes use of that term, yet they do not comprehend the difference between a nerve being impinged AGAINST, and one pinched BETWEEN two harder substances." He further states that as "the spinal nerves are afforded ample space for their emergence from the intervertebral foramina, we will see that normal movements do not compress the spinal cord or spinal nerves."

There is truth to the witticism that everything old is new again.

I do not agree with Dr. Seaman when he states that nociceptive excitation is not nerve interference. We do not need to "rethink our use of the term 'nerve interference.'" Rather, we need to learn the correct definition and use of these words. Interference occurs when two separate things come in contact with each other. The result of this contact is in no way implied by the word interference. When two waves meet, they interfere with each other. The result may be an increase, or decrease, in wave height (frequency) or speed (velocity). Similarly, when a nerve has interference from an outside source, say, a subluxation, we would not be surprised to observe either increased or decreased excitability.

Dr. Seaman's misuse of the word "interference" might be understandable if he were not so well-educated, well-spoken, and considered an expert on neurology within the profession. After all, an ancillary definition of interference is obstruction; but this is not the primary definition. The misuse of a word by a segment of society, whether intentional or not, does not justify the changing of the definition of the word; but it does justify the need for a thorough understanding of the language we choose.

Call it what you will: nerve interference, nociceptive excitation, impingement; just don't assume that your choice of words is the only correct one to convey an idea.

Brian A. Smith, DC
West Hollywood, CA

Dear Editor:

What an interesting article! I am amazed at the bright minds we have in our beloved chiropractic profession!

In the article, "Subluxation Complex and Nerve Interference II," Dr. Seaman suggests the term "nerve interference" is inaccurate and therefore is inappropriate. He articulately points out that the neuropatho-physiologic component of the vertebral subluxation complex seems to be caused by nociceptive excitation.

I suggest that nociceptive excitation resulting in the neuropatho-physiologic component of subluxation is an interference to the normal function of the nerve system, and therefore, simply stated, is "nerve interference."

The next time I'm having lunch with a neurologist, I'll try to work "nociceptive excitation" and "neuropathophysiologic" into the conversation.

However, in the next report of finding with a new patient who wants to know what is causing her ill health, and if chiropractic is a logical and appropriate choice for her and her family, I think "nerve interference" will be much more useful.

Joe. J. Ashton, DC
Canon City, Colorado