Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT
There is considerable frustration with insurance coverage today. It seems any number of plans routinely deny coverage, sometimes for no clear reason. Often, the denial has nothing to do with the provider, the therapies, the techniques or the care plan. It also has nothing to do with how the patient feels, whether the patient likes care or even if they want care. Many times the denial indicates that the care provided is not showing measured benefit for the patient.
Measured benefit is the key here. When you provide treatment, your update notes must show that the progressive care provided is making a difference for that patient. This is not simply an improved number on a 1-10 scale on each visit – that is a subjective measure and is easily dismissed. If the only goal of treatment is making someone feel better, then there are lots of chemical substances – legal and otherwise – which serve that purpose.
As chiropractors, we focus on improving structure and function, and ultimately health. There is more to what we do than just "feel good" and that must be clearly delineated in the patient's record. There are a number of tools / options to draw from that can be used to show measured benefit for a patient:
1. Orthopedic Testing
Orthopedic testing is one of the easiest tools in the box. If a specific maneuver elicits pain and this finding improves with care, that is a positive benefit. As I mentioned before, just one test is not considered enough to render a diagnosis; make sure you have three, four or five tests to the area of complaint. Also note at which point during the maneuver the test is positive. Pain with a SLR at 30 degrees as an initial finding changing to pain at 60 degrees shows improvement. The pain component is still subjective, but the motion to the point of pain shows a significant objective improvement.
2. Functional Capacity Testing
This includes tests such as range of motion and muscle testing. If a patient can't move their neck or raise their arm due to pain, we would count these as initial findings. On update evaluations, we should be able to show improved motion and/or strength. Functional capacity standards typically require these actually be measured. When I was in school, the standard was goniometers and manual resistance, but now there are calibrated tools to measure these findings; often if you do not have specific measurements your assertion of improvement can be questioned.
3. Outcomes Questionnaires
Outcomes questionnaires are also well-established and recognized tools: Neck Disability, Oswestry, Rand-36, etc. It must be understood that these are not meant to measure pain, but to measure how a patient's pain affects their ability to pursue their daily activities. They are objective measures of how the patient's subjective complaints affect function.
4. Palpatory Findings
I am not listing this farther down the list because it is not as important, but because palpation findings vary from provider to provider, and they must be very well-documented. Areas of spasm, congestion, tautness / tenderness, etc., are all reasonable findings. Motion palpation and joint restriction findings should also be noted. In my files I always note which leg is functionally short and which sacroiliac is more fixated. Palpatory findings are important, but should not be the end-all of your objective findings.
5. Patient Information
The patient will often provide valuable objective information, but sometimes you need to ask for it. If they were injured and have gone back to work – that is a measured improvement. If they were only working four hours and are now able to work six – that is a measured improvement. Less rest breaks or downtime, less medication, less need for therapy, and even return to recreation activities can all be considered objective improvements if documented accordingly. Patients in pain often have a loss of sexual function – so return of function would also be an objective improvement. Remember to also note comments from other providers; if another physician states in their record that your care is benefiting the patient, make sure you recognize that in your notes.
Keep in mind that there is no magic recipe. I can't guarantee the above will resolve all the issues of insurance denial, but if your notes clearly document that your care is showing measured benefit for the patient, you will have the tools you need to argue in defense of your care. In addition, I discussed options for the "Objective" part of your daily notes, but don't neglect the "Subjective," "Assessment," or "Plan" sections, either. At the end of the day, it is the responsibility of the doctor to document care and periodically review notes to make sure they accurately delineate the findings and care provided.
