Active care includes the group of procedures in which the patient is active in the encounter. Referred to as therapeutic procedures, these services require constant attendance by the provider and are billed in units of time.
Adding active care to your chiropractic case management procedures is relatively easy, and with only 2-3 CPT codes to learn, correct coding is not complicated. The three procedures commonly included in active care are Therapeutic Activities (97530), Therapeutic Exercises (97110) and Neuromuscular Re-education (97112).
Therapeutic activities are procedures that have the goal of improving the patient's ability to perform an activity of daily living. Therapeutic exercises are procedures with the goal of improving a single functional parameter, such as range of motion, strength or endurance. Neuromuscular re-education has the goal of improving proprioception including, balance, coordination, kinesthetic sense and posture.
Insurance vs. Cash
In states where chiropractic patients receive insurance support for active care, one of the easiest ways to increase the profitability of your practice is by adding active care. In many states, insurance support for therapeutic procedures, including active care, is greater than for the chiropractic adjustment.
Challenges may arise in states where active care is not covered or where there is a cap on fees per visit. In these instances, the provider receives a set amount per visit, regardless of which procedures are performed.
It is not unusual for this payment to be approximately equal to the payment for a chiropractic adjustment alone. This means by the time patients are ready for an active-care treatment protocol, many have already maxed out their chiropractic insurance benefit.
In states with limited or no insurance coverage for active care, becoming part of a Discount Medical Plan Organization (DMPO) can provide a significant benefit. A DMPO allows you to legally discount your fees for non-covered services. Delivering active care procedures can be more costly because it involves the constant attendance of a live person to perform the service. This makes active care procedures more expensive to provide than passive care procedures, such as electric muscle stimulation, that do not require the constant attendance of a provider.
Payment Plans & Prescheduling
Many DMPO providers establish a per diem maximum that includes the fee for the patient's adjustment plus a reasonable additional fee to cover the cost of providing active care. This is where office procedures such as prepayment plans and prescheduling visits become essential.
If patients will be paying a premium of $20-$25 per visit for active care above the fee for an adjustment and are given the option to pay on a per-visit basis, they will view care as an event that occurs during each individual visit, not as a process that occurs over a period of time. If for some reason a patient is not pleased with the result achieved in an individual visit, they may become frustrated and even drop out of care prematurely.
Prepayment and prescheduling can require both procedural and philosophical changes for a practice that is accustomed to collecting payment on a daily or weekly basis and scheduling patients for one to two weeks of care at a time. It is essential to educate patients not to view their care as a laundry list of items they can select or not select to receive. This is evident if you are hearing patients say, "I'll have my adjustment today, but I don't want to do the exercises."
Correct Case Management
When you apply the laws of physiology and the calendar of events that occur during the healing process, you are not going to discharge patients from care simply because their pain goes away. The laws of physiology teach that pain relief comes from a decrease in inflammation and that the inflammatory process is followed by a period of scar formation.
In incidents of acute injury, pain relief due to decreased inflammation should naturally occur within the first 2-3 weeks of care. The replacement of damaged tissue resulting from inflammation with disorganized scar tissue can take an additional several weeks. Scar tissue is not as functional as normal, healthy tissue in terms of strength, endurance and range of motion.
Discharging a patient who has experienced pain relief, but who has not yet had the time to have their non-functional tissue remodeled into normal functional tissue is doing the patient a grave disservice. The likelihood of recurrence and chronicity is significant until complete healing and functional restoration occur.
Correct case management requires you to set measurable, objective goals for care beyond pain relief. If your goal is to return your patients to as complete, normal function as possible, you must begin by knowing what normal is. You should have objective baselines for the functional parameters you are measuring. These include range of motion, outcome assessment measures, muscle strength and endurance, posture, balance and proprioception, among others.
There are well-researched, established normals for each of these measures, and making them a component of your case management procedures is essential. Don't fall into the trap many chiropractors succumb to, telling their patients, "I'm going to see you 2-3 times per week for the next 2-3 weeks and then we'll see how you are doing." This is practicing insurance, not chiropractic.
Active Care Report of Findings
I recommend delivering an active-care report of findings (ROF) once the patient transitions from pain relief to active care. Just as when a patient receives an initial ROF outlining the goal for their chiropractic care, take the time to explain your treatment plan and goals for care during the active phase of care. You will find a significant increase in patients' compliance with your recommendations.
The active care ROF should be scheduled at the point the patient is out of pain: at about the second week of care. I recommend performing a brief functional capacities evaluation at this point to establish a baseline starting point for where the patient is in terms of the functional parameters you will be measuring, monitoring and setting goals toward.
The way I explain it to my clients is to ask them to imagine the name on the sign outside of their office doesn't say ABC Chiropractic, but that it says ABC Physical Therapy. Patients are going to come in with a prescription from their medical provider that says, "Evaluate and treat three times a week for four weeks."
This means there's already an expectation in the mind of the patient that they're going to be there three times a week for four weeks. They readily preschedule their visits because that's already what their expectation is. Why should it be any different in your practice?
Editor's Note: In part 2 of this article, Dr. Sanna discusses active care protocols, equipping your active care suite and staffing considerations.
Continuing to impress the advertising and marketing world, The Foundation for Chiropractic Progress (F4CP) has again been recognized by industry organizations for its excellence in educating consumers on the benefits of chiropractic, this time through social media, newsletters, and demonstrating thought leadership by promoting holistic well-being.
Dr. Louis Sportelli received the Lee-Homewood Chiropractic Heritage Award during the annual conference of the Association for the History of Chiropractic (AHC). During his nearly 60-year career, Dr. Sportelli has embodied the spirit of the award, given to “living individuals who have made outstanding contributions to the chiropractic profession.”
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