The Chiropractic Care Paradigm: Not a One & Done

One of the challenges we face as chiropractors is that we have to cope with our services being compared to and forced into the medical model of health care. Sometimes there are parallels that work; but many times they don't. One of the biggest problems we have with this issue is when reviewers attempt to determine the medical necessity of care by reviewing a single treatment visit. We need to be able to explain how chiropractic works so they can properly and accurately evaluate our claims.

Chiropractic care is episodic in nature and we have two distinctly different types of patient encounters: the assessment or evaluation visit and the treatment visit. (I introduced the concept of the assessment visit / treatment visit paradigm in my article "S.O.A.P.: A Chiropractic Perspective," published in Dynamic Chiropractic on March 1, 2013; and in my book Medicare Documentation System, published later that same year.)

Where We Go Wrong

The problem is that many doctors (and more than a few seminar presenters) are treating the assessment visit / treatment visit paradigm as a one and done. That is to say, they see the stop point of the episode of care as the first re-exam. This is demonstrated by the national average number of chiropractic visits per patient being between 10 and 11 per year.

Many doctors will perform an initial visit, treat the patient for a month, then re-examine the patient and put them on maintenance care. This causes the patient to pay for the care out of pocket – and gives a very incorrect picture to Medicare as to the need for chiropractic care. It cheats the patient out of coverage to which they are clearly entitled; and it cheats the profession by causing third-party payers to expect chiropractic care to be underutilized.

The Assessment / Evaluation Visit

The initial visit is an assessment or evaluation visit and is used to develop a better understanding of the health status of the patient. We use history forms, consultations and examinations to collect the initial information regarding the patient's history and condition. We then use our training and professional judgment to assess the patient's condition, and develop a diagnosis and a treatment plan.

The documentation requirements for the assessment / evaluation visit are the same as for any other doctor: we note all subjective findings from the patient; record all objective test results and observations; assess the patient's condition and note it in the documentation and diagnoses; and formulate a plan of care with measurable goals. We then go over this with the patient and begin treatment.

These visits are conducted at 30-day intervals to measure the progress of the patient and assess the need for any additional care.

The Treatment Visits

The treatment visits are where we put the plan of care or treatment plan into action. We schedule the treatment visits over a 30-day period leading to the next assessment / evaluation visit. We treat the patient's condition utilizing the adjustment techniques and therapies that, in our professional opinion, would be most effective for the patient.

The documentation requirements for the treatment visits are different than those for the assessment visits. We continue to note subjective statements from the patient regarding changes in their condition and objective findings from palpation.

The assessment is limited to determining if the patient is progressing as expected or not. During the treatment visit, the specific levels adjusted, the treatments and therapies administered to the patient and the patient's response to them should be noted.

Visit Blocks and Episode of Care

The assessment / evaluation visits, both prior to and following a group of treatment visits, is referred to as a block of visits. When charted on a calendar, the block of visits should look like this:

This assumes that the initial plan of care called for treatment visits three times per week for four weeks. The block of care is only part of the chiropractic treatment paradigm. The rest involves the episode of care.

The episode of care can consist of as many blocks of care as are necessary for the patient to reach maximum medical improvement. The fact that chiropractors assess the patient's condition at the initial visit, and then treat that condition in a series of treatment visits, means an entire block of care must be analyzed before a determination of medical necessity can be made.

The episode of care starts with an assessment / evaluation visit and continues through the treatment visits leading up to another assessment / evaluation visit 30 days later. This pattern repeats and continues until the patient reaches maximum medical improvement.

The Medicare Benefits Policy Manual, Chapter 15, Section 240.1.5, states the following regarding treatment. The episode of care paradigm outlined here fits within these parameters quite well:

240.1.5 - Treatment Parameters
(Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04)
B3-2251.5

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.

Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already "set" and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.

Practical Takeaway

The chiropractic treatment paradigm is how we interact with our patients. We cannot properly and accurately treat our patients until we identify what is wrong with them. In the same light, we cannot ethically discontinue that treatment until we have documented proof they have benefited as much as they possibly can from our care. To do otherwise would deny our patients the care they need and deserve, and that we are ethically obligated to provide.

For too long, we have allowed others to define us by forcing us into medical models that often do not even come close to representing what we are or what we do. We need to start defining ourselves and insisting others follow our definitions. The chiropractic treatment paradigm provides us a tool we can use to explain our uniqueness to others in the health care community, third-party payers, and state and federal regulators.

Editor's Note: The chiropractic treatment paradigm is further expanded on in Dr. Short's new book, Chiropractic Documentation.