www.ccedseminars Present : Coding, Compliance, & Documentation That Will Get You Paid

1. Coding, Compliance & Documentation
That WILL Get You Paid!
Personal Injury & Work Comp
CCEDSEMINARS
Monte J. Horne, DC
1

2. Special Thanks To Parker University
Our Sponsor
2

3. Preview Hour 1
• Personal Injury Trauma
– Brief neurological assessment
– Documentation pearls
– Clinical pearls
– Red flags
– UCR fees
– Coding pearls
– Indications for testing
– Indications for referral
– Prognosis classification system
3

4. General Overview
• Precautions during exam of significant acute injury
– Collar
• Vitals
• Funduscopic
• Otoscopic
• Brief neurological assessment
4

5. Brief Neurological Assessment
• Mentation
• Pupillary reflex
• Coordination
• DTRs
• Sensory/Motor
• Cranial Nerves
• Neutral lateral film with collar
5

6. 6
1-Brief Neurological Assessment

7. If neurologically intact/stable:
(If signs of instability, transport to hospital immediately)
• Remove collar and complete the exam
• Consider Davis series
7

8. Treatment Overview
• Reassurance: studies have concluded that
uncomplicated cases resolve
• OTC analgesics/NSAIDS 3 weeks or omegas/herbals
• Manipulation
• Exercise
• Quick return to normal activities/work
• Limit passives to the initial 1-3 weeks
• Chiro trial of 2-4 weeks
 Manipulation is contraindicated with evidence of ligament
laxity
8

9. Nutritional Protocol
Acute
- Proteolytic enzymes (trypsin, chymotrypsin, -
bromelin
- Bioflavinoids (quercetin, hesperidin, rutin)
- Herbals (Cats claw, boswella, etc)
Spasm
- Valerian
- Cal/mag 1:2 ration (50/100mg q4h)
9

10. 10

11. Therapeutic Goals
• Return to function not necessarily pain free
• Once MMI is achieved, document residuals and
discharge
• Passive therapy beyond 2-3 weeks may be considered
inappropriate
• No more than 2 passive modalities per season
• Avoid early CT/MRI unless red flags emerge
• Avoid unnecessary referrals w/o clear rationale
11

12. Documentation Pearls
• Complete, organized, & legible file:
– Intake & consent forms including Hx
– Serial pain diagrams
– Baseline & follow-up OATS
– Exam with quantifiable clinical data
– Care plan with quantifiable goals
– Daily notes/procedure requirements
– Appropriately spaced formal reassessments
– Test reports & professional correspondences
12

13. Intake & consent forms including Hx
• PMH
• ROS
• OPPQRST
13

14. 14

15. Outcome Assessment Tools
• Rand/SF-12 or 36
• Neck Disability Index
• Revised Oswestry
• Headache Disability Inventory
• Dizziness Handicap Inventory
• TMJ Scale
• CTS Questionnaire
• UCLA Shoulder Scale
• Functional Index Questionnaire
15

16. Additional OATS
• Beck Depression Index (BDI-II)
• Beck Anxiety Index (BAI)
• MMPI-II
• McGill
• Distress and Risk Assessment Method (DRAM)
• FABQ
• SOAPP
• Waddell
16

17. Examination Data
Examination of the complaint regions/structures may include:
– Inspection and observation to include postural
presentation of the region
– Regional palpation & spinal percussion
– Range of motion including active and/or passive
movement
– Muscle strength
– Provocative maneuvers which might include
compression and stretching
– Neurologic examination
– Vascular examination
17

18. 18

19. Clinical Pearl
• Objective Findings:
Graded Palpation of Tenderness, Spasm, and/or
Swelling.
• Measured provocative maneuvers (e.g. SLR)
• Range of Motion
• Strength
• Activity Restrictions (work/ADLs)
• Other (e.g. Measurement of Balance)
19

20. Clinical Pearl
• The purpose of orthopedic tests is to identify the location
and source of the pain
– Proper documentation: describe the provocation
response
– SLR: At 45 degrees on the right the patient felt
increased pain in the L5 dermatome to the knee
20

21. Orthopedic Tests
• Although a test may be negative according to its
intended definition, a different provocation response may
provide important information to the evaluator even
though it may not be the desired response as described
in the literature.
21

22. 2-Chart Talk
22

23. Side note: 3T MRI
• The increased magnet strength gives many benefits at
no additional expense
• It gives the ability to scan faster or to scan with higher
detail
• Superficial temporal arteritis can be diagnosed without
biopsy.
• 2x the contrast enhancement you would get at a lower
field strength like 1.5T.
23

24. The Diagnosis
• The diagnosis must be supported by the history and
physical examination.
24

25. Care Plan w/Goals
• Treatment Plan: The treatment plan should include the
following:
• Initial date of plan
• Recommended level of care (duration and frequency of
visits)
• Specific treatment goals; and
• Objective measures to evaluate treatment effectiveness.
25

26. Care Plan
• The treatment plan should be updated at 2 – 4 week
intervals or sooner if there is a significant change in the
patient’s condition.
26

27. 27
3-Colossus Video

28. Proving Medical necessity
Initial Post 2 week trial
Neck Pain: 6/10 and constant Neck Pain: 4/10 and
frequent
Pain distribution Pain Localizing
Rand SF-36: 56 Rand SF-36: 67
NDI: 46% Disability NDI: 34% Disability
Cervical Tenderness: 3 Cervical Tenderness: 2
Spasm : III Spasm: II
Cervical ROM: 68% of Ave Cervical ROM: 76% of Ave
Other measures may include motor, SLR, swelling, etc.
28

29. Initial Trial
• 3 times per week for 2 weeks
– If improved, continue as appropriate
– If not, change treatment and begin a second trial
– If no improvement after second trial, refer
29

30. Duration of Care
• Complicating factors such as diabetes, significant heart
disease, or other issues may double recovery time.
30

31. Red Flags
• No/inadequate history
• Documentation is missing patient intake forms
• Intake forms with “attorney referral”
• Extensive diagnosis list; pattern of use of
disc herniation/radiculopathy without clinical support
• Treatment plan is missing measurable goals/time period
• Daily visits beyond 1-2 weeks
31

32. Red Flags
• No re-assessments/inappropriate time between re-
assessments
• Early or repeat imaging; no rationale for imaging
• In-house x-rays, no report
• Early referrals
• Reliance on passive modalities beyond the acute phase
• Use of more than 2-3 modalities per visit
• Up coding; 99204, 99205, 98942
32

33. Red Flags
• Decompression
• Laser Therapy
• TENs
• DME items
• Shoe inserts
• Illegible documentation/extensive abbreviations
• Travel card documentation
• MUA
• Spinal US
33

34. Charges
• Medical Fees in the United States published by PMIC
(800-633-7467), www.pmic.com
• Customized Fee Analyzer published by Ingenix (800-
464-3649), www.ingenix.com
• InstaFees published by ChiroCode (800-944-9877),
www.chirocode.com
• The Medicare RBRVS: The Physicians’ Guide published
by the AMA (800-621-8335), www.ama-assn.org
34

35. Fees
• CPT code
75th percentile fee
– 72040 (cervical x-rays) $133
– 72100 (lumbar x-rays) $128
– 97010 (hot/cold $30
– 97012 (traction) $35
– 97014 (EMS) $36
– 97110 (exercise) $50
– 97112 (NMR) $50
– 97124 (massage) $40
35

36. Fees
• CPT code
75th percentile fee
– 97140 (manual) $58
– 97530 (KA) $50
– 98940 (manipulation 1-2 regions) $48
– 98941 (manipulation 3-4 regions) $58
– 98942 (manipulation 5 regions) $69
– 98943 (extra spinal manipulation) $47
– 99203 (E & M service) $136
36

37. Standards of Care
• Guidelines for Chiropractic Quality Assurance and
Practice Parameters, Second Edition; Scott Haldeman,
David Chapman-Smith, Donald Peterson Jr.; 2005.
• http://ccgpp.org/view.htm
• http://www.acatoday.org/level2_css.cfm?T1ID=15&T2ID
=204
• http://www.icabestpractices.org/pdf/ICABPG_final9216_
00ePreface_sep.pdf
37

38. Standards of Care
• http://www.aetna.com/cpb/medical/data/100_199/0107.ht
ml
• ChiroCode Desk Manual, 2013
• AMA Coding Manual, 2012; AMA Press; 2012
• Milliman ambulatory care guidelines, 16th edition,
regarding manipulation
38

39. FYI
• TBCE
– Texas Administrative Code
Next Rule>> TITLE 22 EXAMINING BOARDS
PART 3 TEXAS BOARD OF CHIROPRACTIC
EXAMINERS
CHAPTER 75 RULES OF PRACTICE RULE §75.2
Proper
Diligence and Efficient Practice of Chiropractic:
Failing to conform to the generally accepted
standards of care within the chiropractic profession.
39

40. Daily Notes
• Subjective:
• Objective:
• Assessment:
• Plan:
Manipulation & treatment parameters
Time, what was performed, 1 to 1 contact
Signature(s)
Date
40

41. Documentation & Coding Pearls
• For Procedure Codes 97110, 97112, 97530, & 97535
– Time component ea. 15 minutes ( 8-22, 23 – 38, etc)
– What was specifically performed (PT log)
– One to one contact with physician or therapist (check
the box on SOAP is appropriate)
41

42. Documentation & Coding Pearls
• For procedure code 97140
– Time component ea. 15 minutes ( 8-22, 23 – 38, etc)
– What technique was specifically performed (PT log)
– Performed at location separate than region
manipulated
– Amended with modifier – 59 when used w/9894x
42

43. Documentation Pearl
• Record what passives were administered, where, and
technical parameters (check the box on SOAP)
• Document of chiropractic palpation on examination
• Document segmental dysfunction & manipulation on
SOAPs
43

44. Imaging
• MRI is image of choice
- Neck pain with radiculopathy if severe or progressive
neurologic deficit
- Neck pain with radiculopathy and failure of 4 weeks of
conservative therapy (chiro, meds, PT)
44

45. FYI
Diagnostic imaging of the spine is associated with a high
rate of abnormal findings in asymptomatic individuals.
Herniated disk is found on magnetic resonance imaging
in 9% to 76% of asymptomatic patients; bulging disks, in
20% to 81%; and degenerative disks in 46% to 93%.
What are the implications for indiscriminant imaging?
45

46. Electrodiagnostic Studies
EMG
- EMGs (electromyography) may be useful to obtain unequivocal
evidence of radiculopathy, after 1-month conservative therapy, but
EMG's are not necessary if radiculopathy is already clinically
obvious.
- EMG’s may be required by the AMA Guides for an impairment
rating of radiculopathy.
NCS
- There is minimal justification for performing nerve conduction
studies when a patient is presumed to have symptoms on the
basis of radiculopathy.
46

47. Standing MRI or dynamic MRI
• Not recommended over conventional MRIs
• Standing magnetic resonance imaging (MRI) is
considered experimental, investigational or unproven
• There is a lack of evidence in the published peer-
reviewed scientific literature validating the accuracy,
relevance or value of dynamic, standing or positional
MRI in the diagnosis and treatment of patients with neck
or back pain
47

48. Collaborative Care
• Cervical epidural steroid injection (ESI)
• Criteria for the use of Epidural steroid injections, therapeutic:
– Note: The purpose of ESI is to reduce pain and inflammation, thereby facilitating
progress in more active treatment programs, and avoiding surgery, but this
treatment alone offers no significant long-term functional benefit
– (1) Radiculopathy must be documented by physical examination and
corroborated by imaging studies and/or electrodiagnostic testing
– (2) Initially unresponsive to conservative treatment (exercises, physical methods,
NSAIDs and muscle relaxants)
– (3) Injections should be performed using fluoroscopy for guidance
– 50% effective; Must be used in conjunction with functional restoration
48

49. Cervical Whiplash Syndrome
• MVC
• Sports
• Work
49

50. Complications
• Retropharyngeal space: < 4-8 mm
• Retrotracheal space < 22 mm
• ADI interspace < 3 mm
***Increased ADI is a contraindication for HVLA***
50

51. 51

52. Classification Systems
• Foreman & Croft
• Quebec Task Force
• Both systems are similar based in part by the
classification system of Norris & Watt (1983)
• The prognosis of neck injuries resulting from rear-end
vehicle collisions. J Bone Joint Surg Br. 1983; 65(5):608-
11
52

53. 53

54. Classification Systems
• Classification is based upon:
– presenting symptoms and physical signs
– these classification systems have been shown to be a reliable
basis for formulating a prognosis
– factors which adversely affect prognosis include the presence of:
• objective neurological signs
• stiffness of the neck
• muscle spasm
• pre-existing degenerative spondylosis.
54

55. 55

56. 56

57. Foreman & Croft Classification
Major Injury Category (MIC) Points
– MIC 1: Symptoms w/o objective findings 10
– MIC 2: Symptoms & findings w/o neurological signs 50
– MIC 3: Symptoms & Findings w/ neurological signs
100
Modifiers
– Canal size 10-12 mm 20
– Canal size 13-15 mm 15
– Cervical Kyphosis 15
– Fixation on stress films 15
– Loss of consciousness 15
– Straight cervical spine 10
– Preexisting degenerative changes 10
57

58. Foreman & Croft Classification
Prognosis Groups (add MIC & modifiers)
Group 1: 10-30 points. Excellent prognosis. Minor
residuals such as some spasm & pain
Group 2: 35-70 points. Good prognosis. Residuals
with remote possibility of later neurological
manifestations
Group 3: 75-100 points. Poor prognosis. Residuals
with neurological signs are possible
Group 4: 105-125 points. Residual neurological signs with
possible need for surgical intervention
Group 5: 130-165 points. Unstable. Surgery often indicated
58

59. Documentation That Will Get You Paid
Personal Injury & Work Comp
CCEDSEMINARS
Monte J. Horne, DC
59

60. Workers Compensation
60

61. Preview Hour 2
• Work Injury Trauma
– More documentation and coding pearls with review
– Intro to ICD-10
– ODG
– Physical therapy
– Chiropractic
– Work conditioning
– Work hardening
– Designated doctor opportunities
61

62. ICD-10-CM Diagnosis Codes
• October 1, 2015; NO GRACE PERIOD
• Texas Work Comp will require ICD-10 in October of
2014.
• ICD-10 is a diagnostic coding system implemented by
the World Health Organization (WHO) in 1993 to replace
ICD-9, which was developed by WHO in the 1970s.
• ICD-10 is in almost every country in the world, except
the United States.
• In many ways, ICD-10-CM is quite similar to ICD-9-CM.
The guidelines, conventions, and rules are very similar.
The organization of the codes is very similar. Anyone
who is qualified to code ICD-9-CM should be able to
make the transition to coding ICD-10-CM.
62

63. ICD-10-CM Diagnosis Codes
• FAQ: http://www.aapc.com/ICD-10/faq.aspx#when
Training: http://www.aapc.com/ICD-10/ICD-10-
Implementation.aspx
Training: http://www.aapc.com/ICD-10/anatomy-
pathophysiology.aspx
63

64. ICD-10-CM Diagnosis Codes
• http://www.icd10data.com/
• http://cms.gov/Medicare/Coding/ICD10/
Downloads/ICD10_Introduction_060413
[1].pdf
64

65. ICD-10-CM Diagnosis Codes
• M99 Biomechanical lesions, not elsewhere classified
• M99.0 Segmental and somatic dysfunction
• M99.00 …… of head region
• M99.01 …… of cervical region
• M99.02 …… of thoracic region
• M99.03 …… of lumbar region
• M99.04 …… of sacral region
• M99.05 …… of pelvic region
• M99.06 …… of lower extremity
• M99.07 …… of upper extremity
• M99.08 …… of rib cage
• M99.09 …… of abdomen and other regions
65

66. Free Online Conversion
• http://www.2icd10.com/Convert
66

67. Expand Your Practice With WC
• You Must Be on The TDI Approved Doctor List
• https://txcomp.tdi.state.tx.us/twccprovidersolution/homeh
tml
67

68. Expand Your Practice With WC
• Physical Therapy
• Chiropractic
• Work Conditioning
• Work Hardening
• Chronic Pain Management
• DDE: MMI/IR
68

69. Expand Your Practice With WC
• WC Fee Schedules
• http://www.texmed.org/Template.aspx?id=6611
69

70. Expand Your Practice With WC
• 97012 Mechanical traction therapy 22.46
• 97014 Electric stimulation therapy 20.8
• 97032 Electrical stimulation 25.18
• 97035 Ultrasound therapy 18.09
• 97110 Therapeutic exercises 43.21
• 97112 Neuromuscular reeducation 44.84
• 97140 Manual therapy 40.48
70

71. Expand Your Practice With WC
• 98940 Chiropractic manipulation 37.77
• 98941 Chiropractic manipulation 52.6
• 98942 Chiropractic manipulation 68.46
• 98943 Chiropractic manipulation 35.64
71

72. Expand Your Practice With WC
• 99202 Office/outpatient visit, new 101.84
• 99203 Office/outpatient visit, new 148.56
• 99204 Office/outpatient visit, new 230.98
• 99212 Office/outpatient visit, est 59.11
• 99213 Office/outpatient visit, est 99.14
• 99214 Office/outpatient visit, est 148.42
72

73. Expand Your Practice With WC
• Work Conditioning: 97545/6-WC 36.00/hr x 3 hrs
• Work Hardening: 97545/6-WH 64.00/hr x 8 hrs
• CPMP: 97799-CP 125.00/hr x 8 hrs
• Above are for CARF facilities; non-CARF is 80%
73

74. CARF
• Commission on Accreditation of Rehabilitation Facilities,
CARF
• Independent, nonprofit accreditor of health and human
services
• http://www.carf.org/home/
74

75. The History
• The process by which one determines the diagnosis
should be adequately recorded, legible, and interpretable.
The history plays a critical role in the diagnostic process.
A well-performed history will appropriately identify the
region to be examined and the extent of the condition.

76. The History
The components of the history may include any or all of
the following, dependent on the presentation of the
patient and the judgment of the practitioner:
• Data on identity, including age and sex
• Chief complaint (problem list)
• History of present complaint (OPQRST)
» history of trauma
» description of chief complaint(s)
» quality/character
» intensity frequency
» location and radiation
» onset
» duration
» palliative and provocative factors

77. The History
•
• Family history
• Past health history
» general state of health
» prior illness
» surgical history
» previous injuries, i.e., MVA, workers’ comp.
» past hospitalizations
» previous treatment and diagnostic tests
» medications
» allergies

78. The History
• Psycho-social history
»occupation
»activities
»recreational activities
»exercise
• Social history
»marital status
»level of education
»social habits

79. 4-Medical Records???
80

80. Documenting Pain
• Pain scores & Diagrams
 Visual Analog Pain Score
 Pain Diagram by the APA

81. Outcome Assessments
• General Health Questionnaires (SF-36)
• Neck Disability Index
• Revised Oswestry
• Headache Disability Inventory
• Dizziness Handicap Inventory
• TMJ Scale
• CTS Questionnaire
• UCLA Shoulder Scale
• Functional index Questionnaire

82. Psychometric Assessment Tools
• Beck Depression Index
• Beck Anxiety Index
• MMPI-II
• Distress and Risk Assessment Method (DRAM)
• FABQ
• SOAPP
• Waddell

83. The Examination
Examination of the complaint regions/structures may
include:
– Inspection and observation to include postural
presentation of the region
– Regional palpation
– Range of motion including active and/or passive
movement
– Muscle strength
– Provocative maneuvers which might include
compression and stretching
– Neurologic examination
– Vascular examination as is safe and effective in
diagnosing the patient

84. 5-Computer ROM
85

85. The Clinical Data
• Subjective Complaint Data:
Severity, Frequency, and distribution
• Outcome Assessment:
General Health Status Questionnaire, Condition specific
Questionnaire, and Psychometrics (if indicated)

86. The Clinical Data
• Objective Findings:
Graded Palpation of Tenderness, Spasm,
and/or Swelling.
• Measured Provocative maneuvers (e.g. SLR)
• Range of Motion
• Strength
• Work Restrictions
• Other (e.g. Measurement of Balance)

87. Treatment Plan
• diagnostic/reassessment plan
• practitioner’s treatment plan
• patient’s education and self-care plan
• referral or co-treatment plan

88. Treatment Plan/Goals
• Decrease pain score, frequency, and/or distribution
• Improve Rand-36/12 Scores
• Improve Condition Specific Outcome scores
• Decrease graded (AAR) spasm, tenderness, and/or
swelling
• Improve physiological measures (e.g. ROM, strength,
sensation)

89. Treatment Goals
Initial Post 2 week trial
Neck Pain: 6/10 and constant Neck Pain: 4/10 and frequent
Pain distribution Pain Localizing
Rand SF-36: 56 Rand SF-36: 67
NDI: 46% Disability NDI: 34% Disability
Cervical Tenderness: 3-4 Cervical Tenderness: 2-3
Spasm : 3 Spasm: 2
Cervical ROM: 68% of Ave. Cervical ROM: 76% of Ave.
Other measures may include motor, SLR, swelling, etc.

90. Proving Medical Necessity
Initial Evaluation: Re-evaluations:
Pain severity, timing, Pain severity, timing,
& distribution. & distribution.
OA Questionnaires. OA Questionnaires.
Graded Palpation Graded Palpation
ROM ROM
MMT MMT
Other Measures Other Measures

91. Re-assessments
Question:
Why is important to re-assess my patient at appropriate
intervals?

92. Re-assessments
Answer:
To meet standards of care, minimize risk, establish
subjective and objective clinical gains, and medical
necessity.

93. Official Disability Guidelines (ODG)
• What Is ODG?
• http://odg-disability.com/orderform.htm
• $350.00/year
94

94. Official Disability Guidelines (ODG)
• Treatment Index
• Return-to-Work Guidelines
• Claims Reserving
• Front matter
95

95. Official Disability Guidelines (ODG)
• Forward
– ODG continues to “become” the most comprehensive,
up-to-date, multi-disciplinary, evidence-based clinical
guideline and decision-support tool available.
– When implemented and used by providers, payors
and employers, ODG ensures timely and quality
current best treatments for ill and injured workers,
enables early return-to-work, reduced waste and
fewer disputes.
– All of this translates into lower medical and indemnity
costs and a “healthier” workforce
96

96. Official Disability Guidelines (ODG)
• EDITORIAL ADVISORY BOARD
– Psychologists
– Physicians
– Chiropractors
– Professors
– Medical Directors
– Pharmacists
– Physical Therapists
97

97. Official Disability Guidelines (ODG)
• Financial Support is from sales of subscriptions
98

98. Official Disability Guidelines (ODG)
• ODG Resources:
– Help Desk: odg@worklossdata.com
– ODG Online Training: ODG Good To Go (Top of web
page)
99

99. Expand Your Practice With WC
• Physical Therapy
• Chiropractic
• WC/WH
•
CPMP
• DDE: IR/MMI/RTW
100

100. Physical Therapy
• Ankle: 9 visits over 8 weeks
• Carpal Tunnel Syndrome: Medical treatment: 1-3 visits over 3-5
weeks; Post-surgical treatment (endoscopic): 3-8 visits over 3-5
weeks
• Sprains and strains of elbow and forearm (ICD9 841):
• Medical treatment: 9 visits over 8 weeks
• Post-surgical treatment/ligament repair: 24 visits over 16 weeks
• Sprains and strains of wrist and hand (ICD9 842):
• 9 visits over 8 weeks
• Sprains and strains of hip and thigh (ICD9 843):
• 9 visits over 8 weeks
101

101. Physical Therapy
• Lumbar sprains and strains (ICD9 847.2): 10 visits over 8 weeks
• Sprains and strains of neck (ICD9 847.0): 10 visits over 8 weeks
• Myalgia and myositis, unspecified (ICD9 729.1): 9-10 visits over 8
weeks
• Rotator cuff syndrome/Impingement syndrome (ICD9 726.1;
726.12):
– Medical treatment: 10 visits over 8 weeks
– Post-injection treatment: 1-2 visits over 1 week
102

102. Chiropractic/Manipulation
• NOT recommended for extremities except for arthrofibrosis of
shoulder & hip.
• Cervical & Thoracic Spine: Mild (grade I ): up to 6 visits over 2-3
weeks
• Moderate (grade II): Trial of 6 visits over 2-3 weeks
• Moderate (grade II): With evidence of objective functional
improvement, total of up to 18 visits over 6-8 weeks, avoid chronicity
• Severe (grade III & also auto trauma): Trial of 10 visits over 4-6
weeks
• Severe (grade III & also auto trauma): With evidence of objective
functional improvement, total of up to 25 visits over 6 months, avoid
chronicity
103

103. Chiropractic/Manipulation
• Lumbar ODG Chiropractic Guidelines:
• Therapeutic care –
• Mild: up to 6 visits over 2 weeks
• Severe:* Trial of 6 visits over 2 weeks
• Severe: With evidence of objective functional improvement, total of
up to 18 visits over 6-8 weeks, if acute, avoid chronicity
• Elective/maintenance care – Not medically necessary
• Recurrences/flare-ups – Need to re-evaluate treatment success, if
RTW achieved then 1-2 visits every 4-6 months when there is
evidence of significant functional limitations on exam that are likely
to respond to repeat chiropractic care
104

104. Work conditioning
• WC amounts to an additional series of intensive physical therapy
(PT) visits required beyond a normal course of PT, primarily for
exercise training/supervision (and would be contraindicated if there
are already significant psychosocial, drug or attitudinal barriers to
recovery not addressed by these programs). See also Physical
therapy for general PT guidelines.
• WC visits will typically be more intensive than regular PT visits,
lasting 2 or 3 times as long. And, as with all physical therapy
programs, Work Conditioning participation does not preclude
concurrently being at work.
• Timelines: 10 visits over 4 weeks, equivalent to up to 30 hours.
105

105. Work Conditioning
• Completed Lower Levels Of Care
• No Psych barriers
• No Modified Duty
• Capabilities Below RTW Requirements
106

106. Work Hardening
• There has been some suggestion that WH should be aimed at
individuals who have been out of work for 2-3 months, or who have
failed to transition back to full-duty after a more extended period of
time, and that have evidence of more complex psychosocial
problems in addition to physical and vocational barriers to
successful return to work. Types of issues that are commonly
addressed include anger at employer, fear of injury, fear of return to
work, and interpersonal issues with co-workers or supervisors. The
ODG WH criteria are outlined below.
107

107. Work Hardening
• Completed Lower Levels Of Care
• Mild-Moderate Psych barriers
• No Modified Duty
• Capabilities Below RTW Requirements
108

108. 109
6-Work Conditioning/Work Hardening

109. Chronic Pain Management Programs
(CPMP)
• Recommended where there is access to programs with proven
successful outcomes (i.e., decreased pain and medication use,
improved function and return to work, decreased utilization of the
health care system), for patients with conditions that have resulted in
“Delayed recovery.” There should be evidence that a complete
diagnostic assessment has been made, with a detailed treatment
plan of how to address physiologic, psychological and sociologic
components that are considered components of the patient’s pain.
Patients should show evidence of motivation to improve and return
to work, and meet the patient selection criteria.
110

110. CPMP
• Completed Lower Levels Of Care
• Moderate-Severe Psych barriers
• No Modified Duty
• Capabilities Below RTW Requirements
• Drug Dependency
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111. CPMP
• Cognitive Behavioral Therapy
• Chiropractic/PT/OT
• Medication Titration
• Occupational Therapy & Retraining
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112. Designated Doctor
• A designated doctor is a doctor selected by Texas
Department of Insurance, Division of Workers’
Compensation (TDI-DWC) to make a recommendation
about an injured employee’s medical condition or to
resolve a dispute about a work-related injury or
occupational illness.
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113. Designated Doctor
• Attend a designated doctor and impairment rating course
that is approved by TDI-DWC.
• Pass an impairment rating test approved by TDI-DWC.
This test must be completed and passed before applying
for the Designated Doctor List.
• Submit an online application through
TXCOMP (TXCOMP provides online assistance to DWC
customers.)
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114. Designated Doctor
• Required Certification Training
– Designated doctors, doctors authorized to certify
maximum medical improvement/impairment rating
and ancillary health care providers must attend this
training every two (2) years. Medical doctors (MD)
and doctors of osteopathic medicine (DO) earn
20 hours and chiropractors (DC) earn 18 hours of
continuing education credit by attending this
training.
– http://www.tdi.texas.gov/wc/dd/training.html#required
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115. Designated Doctor
• Once approved by the Texas Department of Insurance-
Division of Workers Compensation and the proper
training has been completed, physicians are placed on
the Designated Doctor List and medical examinations
requested will be performed by the next available doctor
whose credentials are appropriate for the issue in
question and the injured employee's medical condition.
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116. Designated Doctor
• Other Opportunities:
– FCE
– RTW Evals
– Extent of Injury
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117. Designated Doctor
• Resource:
– http://www.aadep.org/
• Training
• Exams
• Fellowships
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118. Some Thing to Think About…
• Spine 2012:
– 43% on patient that see an ortho first underwent
surgery
– 1.5% of patients who saw a chiro first underwent
surgery
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119. A Final Thought
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120. From Our Family To Yours
Blessings,
&
Success
In 2014
Dr. Monte & Betty Jo Horne
ccedseminars.com
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