2. Schmidt Law Firm
LOVES
Chiropractors!!!

3. In spite of their
Manipulative
Personalities!

4. Question on vocational aptitude test:
Re- arrange the letters P-N-E-S-I to spell out
The part of the body that is most
useful when erect and hard……….

5. Those who spelled SPINE,
became Chiropractors.

6. The rest became Lawyers!
(Often referenced by that part of the anatomy
starting with the letter P!)

7. WELCOME TO THE WORLD OF ICD 10!!!
Starting October 1, 2015, you are there-like it or not!!!
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the United States’ adaption of the World Health Organization’s (WHO) ICD-10 set of diagnosis codes.
Most payers have indicated that ICD-9-CM codes will continue to be required when reporting services which occurred before October 1, To avoid confusion, split the claims so that services after the deadline are on their own claim.
Many providers started using both ICD 9 and ICD10 codes side-by- side as early as July of 2014 (PDR).

8. You Can’t Escape ICD-10-CM
ICD-10-CM is replacing ICD-9-CM as the HIPAA- approved code sets. Healthcare providers and payers are required by law to submit all HIPAA electronic transactions with the ICD-10 code set as of October 1,

9. READY, SET, GO!!!

10. SOME PAYERS NOT SWITCHING
-Not all payers are required by federal mandate to abide by HIPAA. For example, Workers Compensation or Personal Injury Claims do not have to be HIPAA compliant. As such, they are not required to use the ICD- 10-CM code set. Be aware of individual payer policies. -State Farm-requires ICD 10. No written policy. Software “does it” based on adjuster imput! (Garbage in-Garbage out?) Will explain in reason for denial. -American Family-similar to State Farm, but not absolute requirement. -Progressive requires either ICD 9 or ICD 10, but recommends ICD 10. -Farmers requires neither, “strongly suggests” ICD 10..

11. THIS IS NOT AN ICD 10 TRAINING SESSION!!!
You are 5 days away. You and your staffs should be fully trained and fully able to implement the transition to ICD10.
Training
Plan of Action
Software
Cheat Sheets
Purpose of this presentation: To discuss how things will change and how we all might be better prepared for the change.

12. MORE CODES-NEW TERMS-MORE DETAIL
ICD-10-CM is not just an update of ICD-9-CM. The classification system has been fundamentally restructured to include the use of more characters (up to seven instead of five).
By using letters in addition to numbers, as was the case for ICD-9- CM codes, there are up to three times the choices for each of the seven digit code positions. More terms: ICD-10 lists about 68,000 diagnoses, compared to approximately 13,000 for ICD-9.
This allows greater specificity. Now, instead of merely describing a broken bone, ICD-10-CM can describe which bone, which side of the body, what part of the bone, and the status of the break. The same is true for problems in the head and neck.

13. Quick Facts ICD-10-CM consists of the following:
Tabular lists which contain cause-of-death titles and codes
Inclusion and exclusion terms for disease/ cause-of-death titles
Alphabetic Index to diseases and nature of injury
External Causes of Injury
Description, Guidelines and Coding Rules

14. FEATURES OF ICD 10
The Clinical Modification of1CD-10-CM was developed after a thorough evaluation, with input from technical advisors, physician groups, clinical coders, and other relevant organizations to ensure that users would experience consistency and accuracy in diagnostic coding. ICD-10-CM improvements include:
Additional codes relevant to ambulatory and managed care encounters;
Combination codes for diagnosis and symptoms, which reduce the number of diagnosis codes needed to describe some conditions;
Expanded injury codes, with code extensions for injuries and external causes of injury;
Placeholders (designated by use of an "x") allow for future additional entries;
Longer codes—up to seven characters, include four-digit and five-digit subcategories;
Laterality, to indicate which side of the body is affected;
Additional alcohol and substance abuse codes;
Greater specificity in code assignment;
Alphanumeric categories instead of strictly numeric categories—almost twice as many categories.

15. Performance Differences
Laterality: The extra characters available per code in 1CD-10-CM mean that extra details can be added for each diagnosis. For instance, it is possible to code for conditions that can occur on the right or left side of the body, or bilaterally. This capability is called "laterality.“
Encounter Specific: There is also the ability to specify upon which encounter the diagnosis is cen­ tered—initial, subsequent, or sequelae (late effects). This capability is out of the reach of ICD-9- CM.
Commonly Combined Codes: Combination codes are also a new concept withinICD-10-CM. Some conditions were "grouped" together in ICD-9-CM for lack of space. This change allows for more accurate coding for things such as frequent co-morbidities.
Expandability: There are enough codes available within ICD-10-CM for things that were not feasible to code within the limits of the ICD-9-CM structure. There are actually diagnoses codes for blood alcohol and blood type/RH factor.

16. A BLESSING AND A CURSE!!!
The CURSE is that implementation of ICD 10 will require more detailed records and documentation. It will involve more paperwork and time involvement. It will potentially involve problems with adaptation to the expectations/demands of the payer. Payers will use “coding errors” as a reason not to pay!
The BLESSING is that ICD 10 will require better practice. Better history-taking, more detailed examination, more detailed diagnosis. The coding is simply the frosting on the cake. The baking of the cake will required upgrades in procedure.

17. YOU WILL BE BETTER PRACTITIONERS
You have no choice.
Your codes will have to be accurate.
Your notes will have to establish medical necessity.
Medical necessity = the items of service being provided must be reasonable and necessary for the diagnosis and treatment of the illness or injury or to improve the functioning of a malformed body member.

18. PERSONAL INJURY LAWYERS NEED TO KNOW TOO
Any PI lawyer who expects to be competent needs to understand the basic principles of anatomy and biomechanics of personal injuries of the spine and other body parts. The competent PI lawyer needs to understand chiropractic. For the same reasons, the competent PI lawyer should know and understand ICD coding, CPT coding and the documentation that is necessary to support medical necessity.

19. CMS WILL PROVIDE GUIDANCE…
Q1. What if I run into a problem with the transition to ICD-10 on or after October 1st 2015?
A1. CMS understands that moving to ICD-10 is bringing significant changes to the provider community.
CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10.
As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns.
As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman,

20. CMS SAYS NO DENIAL IF…
Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?
A1. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.
However, a valid ICD-10 code will be required on all claims starting on October 1, It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

21. CMS SAYS NO PENALTY IF…
Q3. What happens if I use the wrong ICD-10 code for quality reporting? Will Medicare deny an informal review request?
A3. For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes.
Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes.
CMS will not deny any informal review request based on 2015 quality measures if it is found that the EP submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes).
CMS will continue to monitor the implementation and adjust the timeframe if needed.

22. CMS OFFERS ADVANCED PAYMENT
Q4. What is advanced payment and how can I access this if needed?
A4. When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section are met.
To apply for an advance payment, the Medicare physician/supplier is required to submit the request to their appropriate Medicare Administrative Contractor (MAC). Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments. CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.

23. PRACTICE POINTERS Use correct codes!
Keep close watch on policies of individual payers. Share info.
Watch for the “Excludes1”, “Excludes2” and “Includes” rules.
Your record must support the code selected. (Good notes, better pay!)
Be specific about location of muscle spasm and MTPs and degree of limited ROM.
6. Records should justify treatment frequency/duration. (Croft/MCA)

24. RECORD KEEPING REQUIREMENTS OF MN CHIROPRACTIC BOARD.
All items in this part should be contained in the patient record. However, a record to justify patient care must contain items A, B, C, E, G, and I.
A description of past conditions and trauma, past treatment received, current treatment being received from other health care providers, and a description of the patient's current condition including onset and description of trauma if trauma occurred.
Examinations performed to determine a preliminary diagnosis based on indicated diagnostic tests, with an indication of all findings of each test performed.
A diagnosis supported by documented subjective and objective findings or clearly qualified as an opinion.
A treatment plan that describes the procedures and treatment used for the conditions identified, including approximate frequency of care.
Daily notes documenting current subjective complaints as described by the patient, any change in objective findings if noted during that visit, a listing of all procedures provided during that visit, and all information that is exchanged and will affect that patient's treatment.

25. RECORD KEEPING REQUIREMENTS OF MN CHIROPRACTIC BOARD.
Minnesota Rule RECORD KEEPING (cont’d)
A description by the chiropractor or written by the patient each time an incident occurs that results in an aggravation of the patient's condition or a new developing condition.
Results of reexaminations that are performed to evaluate significant changes in a patient's condition, including tests that were positive or deviated from results used to indicate normal findings.
When symbols or abbreviations are used, a key that explains their meanings must accompany each file when requested in writing by the patient or a third party.
Documentation that family history has been evaluated.

26. JOE BLOW’S CAD INJURY.
Forman & Croft: CAD =s Cervical Acceleration/Deceleration Injury.
Common components:
Cervical strain (muscle injury-muscle spasm, myofascial trigger points, MPS).
Cervical sprain.(ligament injury)
Disc injury.
Facet joint injury.
Concussion/Traumatic Brain Injury.

27. SPRAIN VS. STRAIN
National Institute of Health definitions:
Strain = a stretched or torn muscle or tendon. Symptoms include pain, muscle spasm, swelling, and trouble moving the muscle.
Sprain = a stretched or torn ligament. Symptoms include pain, swelling, bruising, and being unable to move the joint.

28. Strain Codes (Muscle): Sprain Codes (Ligament):
SPRAIN VS. STRAIN
Strain Codes (Muscle):
1) S16.1xx_
2) M62.83
3) M79.1
Sprain Codes (Ligament):
4) M99.01
5) M99.10 6)

29. CODING FOR SPRAIN/STRAIN
S16.1xx_ Strain of muscle, fascia and tendon at neck level.
M62.83 Muscle Spasms & Back
M79.1 Myalgia- Myofascial Pain Syndrome
M99.01-Segmental and somatic dysfunction of cervical region
M99.10-Subluxation complex (vertebral) of cervical region
S S Dislocation of cervical vertebrae, specifying the exact level.
M53.2x1, 2, 3 Spinal instabilities (specify the region).

30. A Closer Look at Specifity
M99.0 Segmental and somatic dysfunction
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
M99.06 Segmental and somatic dysfunction of lower extremity
M99.07 Segmental and somatic dysfunction of upper extremity
M99.1 Subluxation complex (vertebral)
M99.11 Subluxation complex (vertebral) of cervical region
M99.12 Subluxation complex (vertebral) of thoracic region
M99.13 Subluxation complex (vertebral) of lumbar region
M Subluxation complex (vertebral) of sacral region
M Subluxation complex (vertebral) of pelvic region

31. STRAIN-MYOFASCITIS/MYOFASCIAL PAIN SYNDROME
ICD 10 CODING FOR MPS
M79.1 Myalgia-Myofascial pain syndrome
Excludes 1:
Fibromyalgia (M79.7)
Myositis(M60)
It is important to remember the significance of the terminology “excludes 1” vs. “excludes 2”.
“Excludes 1” means that the code should never be used at the same time as the code above the “Excludes 1” note. (I.e. the patient cannot have both conditions at the same time.)
“Excludes 2” means that the condition excluded is not part of the condition being coded, but that the patient can have both conditions at the same time.

32. MYOFASCITIS/MYOFASCIAL PAIN SYNDROME
Dr. Jack Hubbard, “Myofascial Trigger Points: What Physicians Should Know about these Neurological Imitators”, Minnesota Medicine Journal, May 2010:
Definition of MPS:
Myofascial trigger points are pathologic changes within muscle segments that are usually caused by trauma such as a motor vehicle accident…identified on examination as painful knots and taut bands within the affected muscle, trigger points are capable of producing neurological symptoms including headache, dizziness, and sensory disturbances.
Trigger Point Examination:
MFTPs can be objectively identified during a careful examination of the patient.
Any skeletal muscle can develop trigger points, which can be identified by careful examination of the affected muscle groups for knots that are 2 mm to 5 mm in diameter and tight bands that are painful when palpated. Diagnosis is based on the patient's history and examination; there are no laboratory tests or imaging studies that can confirm the presence of MFTPs.

33. AMA-Myofascial Pain Syndrome
“Myofascial Pain Syndrome is a condition of mild to severe muscle pain associated with trigger points, the pain is typically localized, often to a single muscle. The syndrome commonly follows “muscle overload,” such as may occur with acute injury (e.g., following a near fall or intense exertion). Patients complain of a deep, aching pain that is worsened by activity. Postural muscles are often affected. The pain may wax and wane, but it is usually always present and at times can be severe.
Assessment and Diagnosis of Myofascial Pain
Trigger points are a diagnostic feature of this syndrome. On physical exam there will be muscle tenderness and limited range of motion, and these may be associated with palpable trigger points or “taut bands.” Palpating the trigger point produces a local twitch (a visible shortening of the muscle) and referred pain most often involves the posterior neck, low back, shoulders, chest. Chronic pain in the muscles of the posterior neck can refer to muscles in the head and cause persistent headaches; trigger points in the lower back muscles can cause referred pain to the leg that mimics sciatica.
Source: AMA Pain Management, An American Medical Association Continuing Medical Education Program for Primary Care Physicians

34. Managing Myofascial Pain
“The primary treatment for myofascial pain involves releasing the trigger points, which can be accomplished by stretching the affected muscle. One treatment, the “spray and stretch technique” involves stretching the muscle in conjunction with topical application of vapo- coolant sprays. A sudden drop in the skin temperature is thought to be associated with a localized anesthetic effect, which allows the affected muscle to be stretched. Massage of the trigger points may also provide pain relief. Provoking factors such as poor posture and repetitive work should be avoided.
Nonpharmacologic management. In addition to “spray and stretch” and massage, other nonpharmacologic approaches include osteopathic manipulation, application of heat or ice, ultrasound exercise, TENS, acupuncture, and biofeedback. Reports of treatment effectiveness are based more on empirical clinical experience than data form controlled trials.”
Source: AMA Pain Management, An American Medical Association Continuing Medical Education Program for Primary Care Physicians

37. LIGAMENTOUS SPRAIN/WHIPLASH
Note S13.4xx_ Sprain of ligaments of cervical spine
Sprain of anterior longitudinal ligament, cervical;
Sprain of atlanto-axial joints;
Sprain of atlanto- occipital joints
Whiplash injury of cervical spine.

38. Includes and Excludes2
S13 DISLOCATION and SPRAIN of joints and ligaments at neck level
Includes:
Avulsion of joint or ligament at neck level
Laceration of cartilage, joint, or ligament at neck level
Sprain of cartilage, joint, or ligament at neck level,
Traumatic subluxation of joint or ligament at neck level
Traumatic tear of joint or ligament at neck level
Excludes2: Strain of muscle or tendon at neck level (S16.1)

39. Many ligaments of the cervical spine are ligamentous injuries and permanent.

40. “Sub-failure” (stretch only) Ligamentous Injuries Are Serious!
Stretch (distension) damage resulted in abnormal laxity equal to having “no ligamentous support” at all!!!
Partial injury to these ligaments resulted in laxity equivalent to “completely compromised” ligaments.

41. SUBLUXATION/DISLOCATION/BOTH?
S13 DISLOCATION AND SPRAIN OF JOINTS AND LIGAMENTS AT THE NECK LEVEL Includes: -sprain of cartilage, joint or ligament at neck level; -traumatic subluxation of joint or ligament at neck level; -traumatic tear of joint or ligament at neck level. Excludes 2: Strain of muscle or tendon at neck level (S16.1) Note: The appropriate 7th character is to be added (A, D, S)

42. AMA EATS CROW REGARDING SUBLUXATION
Since 1993 the American Medical Association now recognizes ligamentous laxity to be an important cause of permanent disability. The AMA uses the terminology of:
AOMSI is Alteration of Motion Segment Integrity. (Does that sound like “subluxation”?)
LOMSI is Loss of Motion Segment Integrity.
The AMA Guides to the Evaluation of Permanent Impairment, 4th Edition, 5th Edition and 6th Edition both recognize AOMSI as a basis for the assessment of permanent impairment of the spine when verified by flexion/extension Xrays:
The term “alteration of motion segment integrity” was first used in the Fourth Edition of the Guides to describe loss of motion segment integrity, identified on flexion/extension X -rays (following specific protocols) and related to either instability or fusion, regardless of the cause.

43. SURE SOUNDS LIKE A SUBLUXATION!!!
For all of 118 years since Daniel David Palmer founded the discipline of Chiropractic Medicine, the medical community has scoffed at the concept of “subluxations”!! The American Medical Association publicly declared chiropractic to be an “unscientific cult”. They finally figured it out-but refuse to use the terminology of “subluxation” that the DC community has known and appreciated for decades.

44. As early as 1993, the AMA Guides stated:
AMA Guide to Evaluation of Permanent Impairment 4th Edition “The loss of (motion segment) integrity is defined as: -an antero-posterior motion or slipping of one vertebrae over another greater than 3.5 mm for a cervical vertebrae are greater than 5 mm for a vertebrae in the thoracic or lumbar spine; or -a difference in the angular motion of two adjacent motion segments greater than 11° in response to spine flexion and extension. Motion of the spine segments is evaluated with flexion and extension. (Loss of integrity of the lumbosacral joint is defined as an angular motion between L5, and S1 that is 15° greater than the motion at the L4, L5 level.)”

46. TRANSLATIONAL ABNORMALITY:
Anterolisthesis/Retrolisthesis:

47. ANGULARAL MOTION ABNORMALITY
Disruption of George’s Curve

48. NORMAL/IMPAIRMENT Abnormal is: Side slippage at C1-2 of 1.7
Angular instability of +7 mm
Translational instability Y + 1mm
25% Impairment is:
Angular instability of 11+ degrees
Translational instability of 3.5+ mm

49. New Data From Schmidt Law Firm cases:
Over 90% of our clients (102cases) who have been CRMA’d have evidence of abnormal ligamentous laxity.
35% have sufficient laxity to qualify for a 25% Impairment rating using the AMA Guides.
40% have abnormal shifting of the Atlas that corresponds to high cervical and occipital pain and headaches. (Those with bilateral shifting have bilateral headaches. Those with unilateral shifting have unilateral symptoms.)

50. CRMA can quantitatively analyze the extent of the ligamentous laxity.
CRMA is Computerized Radiographic Mensuration Analysis, or CRMA. It is also called “digitized x-ray.” The term “mensuration” simply means “the measurement of geometric quantities.” Medical and chiropractic doctors have, for nearly 100 years, been measuring the translational and angular malpositioning of vertebrae.
CRMA means to measure radiographics (x-ray) using a computer. Thus CRMA provides for accurate, computerized measurement of the malpositioning of vertebrae due to ligamentous laxity.

51. CRMA can be used to establish a percentage impairment rating using the AMA Guides rating system.
Motion of the individual spine segments cannot be determined by physical examination, but is evaluated with flexion and extension roentgenograms (see Figures 15-3a through 15-3c) AMA Guides, (5th Ed. 2001), pg. 379.

52. CRMA can be used to provide an AMA-based disability rating.
The AMA Guides to the Evaluation of Permanent Impairment, 5th Ed. (2000), p. 392, states that Alteration of Motion Segment Intergrity (AOMSI) results in a 25-28% impairment rating in each of the following cases:
Alteration of Motion Segment Integrity or bilateral or multilevel radiculopathy; alteration of motion segment integrity is defined from flexion and extension radiographs as at least 3.5 mm of translation or one vertebrae on another, or angular motion of more than 11 degrees greater than at each adjacent level.

53. How do we know that the ligamentous laxity was caused by CAD trauma?
When routine x-rays are normal and severe trauma is absent, motion segment alteration is rare; thus, flexion and extension x-rays are indicated only when the physician suspects motion segment alteration from history or findings on routine x-rays. AMA Guides, 5Ed. 2001, pg. 379.
The flip side of the coin is that when severe trauma is present and digital motion Xrays show laxity, motion segment alteration is likely present.

54. Ligamentous Laxity Causes Accelerated Degeneration of the Intervertebral Discs.
“the lack of motion at one level will be compensated for by hypermobility at adjacent levels, which in turn usually will result in degenerative disc disease and osteoarthritis sometime in the future.”
Delayed instability of the spine due to ligamentous laxity is recognized in the medical literature. CRMA is a valuable tool in detecting delayed instability of the ligaments. See Cusic, Clinical Biomechanics, Vol. 17, No 1, pp (2002)

55. RESULTS OF CRMA-SCHMIDT LAW FIRM
The Schmidt Law Firm has had 102 clients CRMA’d with these results:
There is a high degree of correlation between the specific
location of the ligamentous laxity and the specific location of the symptoms.
location of the ligamentous laxity and the specific location of the disc pathology.
Patients with ligamentous laxity have demonstrated grossly accelerated disc degeneration on repeat MRIs.
There is a high degree of correlation between laxity of the
Atlas and occipital symptoms/occipital headaches.

56. DOCUMENTATION-DIAGNOSIS & TREATMENT OF STRAIN INJURY.
1. Pain documentation-Numerical rating, and Oswestry.
“Accurate assessment of acute pain is essential for the development of an effective pain management plan. A comprehensive pain assessment should e preformed when patients present with pain and at the onset of new acute pain.”
2. Muscle spasm-Identify the specific areas of spasm.
3. Swelling/edema of the muscles.
4. Limitation of range of motion, using degrees (inclinometer).

57. STATEMENT OF MEDICAL NECESSITY
THE SUPPORTING CHART NOTES SHOULD ALWAYS CONTAIN A STATEMENT OF MEDICAL NECESSITY FOR BOTH THE FREQUENCY AND DURATION OF TREATMENT, using either the Croft Guidelines or the MCA Standards of Practice.
The Croft Guidelines should be referenced “Best Practices & Practice Guidelines” #NGC-7125, U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality.
The MCA Standards of Practice pre-dated the Croft standards. Is there any evidence that they have been officially replaced by the MCA or otherwise?

58. CROFT GUIDELINES-GRADES OF INJURY
Croft’s Grades of Injury
Grades
Severity
Anatomical and Clinical Description I
Minimal
No limitation of range of motion, no ligamentous injury, no neurological symptoms II
Slight
Limitation of range of motion, no ligamentous injury, no neurological findings
III
Moderate
Limitation of range of motion, some ligamentous injury, neurological findings present IV
Moderate to Severe
Limitation of range of motion, ligamentous instability, neurological findings present, fracture or disc derangement V
Severe
Requires surgical treatment and stabilization

59. CROFT GUIDELINES-GRADES OF INJURY
DISTINGUISHING FACTOR LIGAMENTOUS INJURY!

60. CROFT FREQUENCY/DURATION/TREATMENT
Grade
Daily
3x/wk
2x/wk
1x/ wk
1x/ mo
Duration #
Visits
ICA Equivalent
Grade I
1 wk
1-2 wk
2-3 wk
> 4 wk
_ _ _
> 10 wk 21
# 1 C
Grade II
> 4 mo
> 29 wk 33
# 2 C
Grade III
> 6 mo
> 56 wk 76
# 6 C
Grade IV
>16 wk
>12 wk
>20 wk **
Grade V
Surgical stabilization necessary- chiropractic care is post surgical

61. TREATMENT DURATION-LIGAMENTOUS INJURY
Grade
Daily
3x/wk
2x/wk
1x/ wk
1x/ mo
Duration #
Visits
ICA Equivalent
Grade I
1 wk
1-2 wk
2-3 wk
> 4 wk
_ _ _
> 10 wk 21
# 1 C
Grade II
> 4 mo
> 29 wk 33
# 2 C
Grade III
> 6 mo
> 56 wk 76
# 6 C
Grade IV
>16 wk
>12 wk
>20 wk **
Grade V
Surgical stabilization necessary- chiropractic care is post surgical

62. PERMANENT PALLIATIVE CARE
The Croft Guidelines justify “permanent palliative care” in the following cases:
Grade IV-Moderate to Severe:
Limitation of range of motion,
Ligamentous instability,
Neurological findings present, OR
Fracture OR
Disc derangement.

63. MCA STANDARDS OF PRACTICE
For “Traumatic Moderate Sprain/Strain Injuries:
This injury should demonstrate a favorable response to chiropractic rehabilitative management over the course of 1-5 months, with up to 6-12 months of PRN care to determine the stability of the condition.
Again, documentation of ligamentous instability is the key!!!

64. MCA STANDARDS-SEVERE SPRAIN/STRAIN
For Severe Sprain/Strain Injuries:
Is this injury she demonstrated favorable response to chiropractic rehabilitative management over the course of 1 to 11 months, with up to 18 – 24 months of PRN care to determine the stability of the condition. Some of these injuries/conditions will require further active care beyond 11 months. Other injuries/conditions may result in some degree of permanent impairment or disability that may or may not require continuing care. If the condition necessitates continuing care, it should be rendered on a PRN basis is described in the section on PRN care.

65. MCA STANDARDS-MYOFASCITIS
For Mild, Moderate, Considerable, or Severe Myofascitis, DJD, Stenosis;
“See section on PRN care.”
Note: this would included cases of MPS, as well as aggravations of pre-existing DJD and stenosis.

66. DISC INJURIES M50 CERVICAL DISC DISORDERS
Code to the most superior level
Includes:
-cervicothoracic disc disorders with cervicalgia
--cervicothoracic disc disorders
M50.0 Cervical disc disorder with myelopathy (spinal cord involvement)
M50.1 Cervical disc disorder with radiculopathy.
Notes should support “aggravations”!!!

67. MEDICAL NECESSITY FOR MRI
MRI is the single best test to determine the presence of disc injuries.
The clinical signs that justify the medical necessity for an MRI are:
Radiculopathy &/or Paresthesia
Neurologic deficit
Nature and extent of injury to spinal cord-vertebral column-ligaments and interspinal soft tissues following trauma
Muscle-tendon-ligament tears
Spinal instability
Ligament laxity
Failure to respond as expected to conservative care
Source: ACR American College of Radiology-(ASNR) American Society of Neuroradiology- (AHRQ) Agency for Healthcare Research and Quality

68. DISC INJURIES CAUSE PAIN EVEN WITHOUT IMPINGEMENT OF A NERVE ROOT
Foreman & Croft-
Four ways that an anterior extrusion of an intervertebral disc can convey pain:
(a) via direct compression or irritation of the sympathetic chain ganglia;
(b) via the anastomosis between the recurrent meningeal nerve and its sympathetic connection;
(c) through the direct route into the ventral ramus of the spinal nerve via the white rami communicantes; and
(d) via nociceptive afferent activity (recurrent meningeal nerve) in the anterior anulus.
Both produce pain (direct and referred), muscle spasm, trigger points, further causing abnormal function and movement of the spine.

69. DISC PAIN WITHOUT IMPINGEMENT
Medical literature universally establishes that disc injury causes “vertebrogenic pain” without nerve root impingement.
Jinkins, et. al, “The Anatomic Basis of Vertebrogenic Pain and the Autonomic Syndrome Associated with Lumbar Disc Extrusion,” American Journal of Roentgenology, June 1989, p et. Seq. identifies “the vertebrogenic symptom complex which involves ‘referred pain’ emanating from the injured disc through the autonomic nervous system.”

70. Freemont, et. al, “Nerve Growth into Diseased Intervertebral Disc in Chronic Back Pain,” The Lancet 1997; 350; explains that injuries to the outer third of the annullus fibrosus of the disc can cause the ingrowth of painful nerve fibers which extrude chemical substance causing pain plays an “important role in the pathogenesis of chronic low back pain.”
Bogduk et. al, “The Innervation of the Cervical Intrvertebral Disc,” Spine, Vol. 13, No. 1, pp. 1-8 (1987) states that “there has been no doubt that lumbar intervertebral discs are innervated…(and) the innervation is not just in their superficial layers but can be found as deep as the outer third of the annulus fibrosus” so that disc injuries that do not impinge on a nerve root or the spinal cord can be expected to be painful. This article states that studies have shown that the same is true of cervical discs, i.e. that injury to the disc can cause pain.

71. FACET JOINT INJURIES Present 60% of Chronic Pain Cases.
Ligament laxity can be detected by a careful clinical examination of the laxity of each vertebral joint in all 8 planes of motion (flexion-extension, rotation, side bending, and protraction/retraction. Findings of ligamentous laxity should be carefully documented in the record
Palpation of the facet joint in pillar examination will often produce radiation of symptoms in a well-established dermatome region. (See next slide) Radiation of symptoms within the dermatome region should be carefully documented
Facet joint damage is linked to myofascial trigger points. Myofascial trigger points can be detected by a careful examination. The location of each trigger point, naming the muscle group, should be carefully documented
Gold standard of DX: Medial Branch Block Injections
Treatment: Radiofrequency Neurotomy

72. DERMATOME CHART

73. CONCUSSION INJURIES DON’T OVERLOOK THE CONCUSSION INJURY!!
The experience of the Schmidt Law Firm indicates that over 50% of the victims of moderate to severe whiplash injury have suffered a concussion and are experiencing post-concussion symptoms.
A recent medical journal reported a study that showed that 45% of ER doctors do nothing to screen for a closed-head injury.
Nearly 100% of MDs don’t perform a proper screen for a period of loss of consciousness.

74. CONCUSSION INJURIES
S06.0 Concussion Commotio cerebri Excludes1: Concussion with other intracranial injuries classified in category (S06-) code to specified intracranial injury S06.0x Concussion S06.0x0_ Concussion without loss of consciousness S06.0x2_ Concussion with loss of consciousness 30 minutes or less S06.0x2_ Concussion with loss of consciousness of 31 minutes to 59 minutes S06.0x9_ Concussion with loss of consciousness of unspecified duration

75. Definition of Loss of Consciousness
“Loss” = Partial loss/ Total loss
Degrees of Consciousness
Total Consciousness
Lethargy
Stupor
Coma

76. PROPER CONCUSSION SCREENING
PROPER SCREEN FOR LOSS OF CONSCIOUSNESS It is completely absurd to screen for loss of consciousness by simply asking the patient if they remember any period of loss of consciousness. That is a self-defeating question!!! It’s really simple!!! If one is unconscious, they are not conscious of the fact that they are unconscious!!! The proper method of screening is to ask the patient to close there eyes and think back. Do you remember the collision? What is the first thing you remember after the collision? If the answer is, “I was sitting behind the wheel and the police officer was knocking on my window”, then there is a clearly defined period of loss of consciousness!!! Do you remember being tossed around? Do you remember bringing the car under control and to a stop? Do you remember hearing the siren of the police car-or the ambulance?

77. DOCUMENTATION-DIAGNOSIS & TREATMENT OF CONCUSION/TBI.
Documentation of Loss of Consciousness.
Definition of Loss of Consciousness.
History re Loss of Consciousness.
Rivermead Questionaire.

78. No Loss of Consciousness- No Blow
A SIGNIFICANT NUMBER OF CONCUSSION INJURIES OCCUR IN THE ABSENCE OF (1) TOTAL LOSS OF CONSCIOUSNESS AND (2) ANY FORCEABLE BLOW TO THE HEAD. Many respected medical tests have for many years firmly established the proposition that concussions (mild TBIs) can result from whiplash trauma even in the absence of any total loss of consciousness and certainly without any forceable blow to the head. It is well established that a disruption of consciousness (confusion, disorientation) is sufficient to establish the existence of a concussion. It is now well recognized by athletic trainers that detailed questioning is necessary to rule-in or rule-out a concussion. (I.e. State the days of the weeks/months of the year in reverse order) The existence or non-existence of a concussion is best determined by use of the Rivermead Post-Concussion questionnaire.

79. RIVERMEAD POST CONCUSSION QUESTIONAIRE.

80. PAIN CODES M54.2 Cervicalgia M53.1 Cervicobrachial syndrome
M53.0 Cervicocranial syndrome
M53.8 Doropathies (spinal condition causing pain)
G44.3 Headache codes.

81. PAIN ASSESSMENT PROTOCOLS
AMA recommends:
Oswestry Neck Pain Disability Index
Oswestry Low Back Pain Disability Index
AMA Pain Related Impairment Rating
Also:
Henry Ford Headache Disability Index
Occupational Therapy FCE

82. PAIN RELATED IMPAIRMENTS
Chronic Pain is the Number One Cause of Disability (and medical expense) in the U.S.
The significance of chronic pain as a medical entity cannot be overlooked. The two major health care organizations in the U.S. today, the AMA and the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) have individually declared chronic pain to be the number one cause of disability in the U.S. workforce.
The AMA Guides to the Evaluation of Permanent Impairment, 5th Ed. has declared pain to be “the most common cause of disability with chronic low back pain alone accounting for more disability than any other condition…”
The Joint Commission for the Accreditation of Health Care Organizations (JCAHO), which accredits all major hospitals in the U.S., has also declared that “chronic pain is the most common cause of long term disability…”
According to the AMA Guides, pain is also one of the most causes of medical treatment in the US today. According to the AMA Guides, “Medical expenses for pain-related assessment and treatment…are estimated to be $125 billion each year in the United States.” (p. 567)

87. DOCUMENTATION-DIAGNOSIS & TREATMENT OF SPRAIN INJURY.
Pain assessment.
Swelling
Limited ROM. (Can laxity due to abnormal ligament stretch be determined on clinical exam?)
Flexion/Extension or Motion Xrays.

88. EXTERNAL CAUSES OF MORBIDITY (V & Y) CODES
The ICD 10 Coding system now requires entry as to the specific cause of injury, with over 250 different codes. The most commonly used will be:
V43 CAR OCCUPANT INJURED IN COLLISION WITH CAR, PICK-UP TRUCK OR VAN.
Note: This is a 7 character code!!!
V43.52x(A,D,S) Car driver injured in collision with other type car in traffic accident.
V43.62x(A,D,S) Car passenger injured in collision with other type car in traffic accident.

89. JOES’ CODES Muscle Strain Codes: Ligament Sprain Codes:
S16.1xx_ Strain of muscle, fascia and tendon at neck level
M Muscle Spasms & Back
M79.1 Myalgia- Myofascial Pain Syndrome
Ligament Sprain Codes:
M Segmental and somatic dysfunction of cervical region
M Subluxation complex (vertebral) of cervical region
Dislocation of cervical vertebrae, specifying the exact level
S13.4xx Sprain of ligaments of cervical spine
Disc injury codes:
M50.0 Cervical disc disorder with myelopathy (spinal cord involvement)
M50.1 Cervical disc disorder with radiculopathy

90. JOES’ CODES External Cause Codes: Concussion Codes: Pain Codes:
S06.0x0 Concussion without loss of consciousness
S06.0x2 Concussion with loss of consciousness 30 minutes or less
S06.0x3 Concussion with loss of consciousness of 31 minutes to 59 minutes
S06.0x9 Concussion with loss of consciousness of unspecified duration
Pain Codes:
M Cervicalgia
M Cervicobrachial syndrome
M Cervicocranial syndrome
M53.8 Doropathies (spinal condition causing pain)
G44.3 Headache.
External Cause Codes:
V43.52x(A,D,S) Car driver injured in collision with other type car in traffic accident.
V43.62x(A,D,S) Car passenger injured in collision with other type car in traffic accident.

91. JOES’ CODES External Cause Codes: Incidental Symptom Codes Pain Codes:
M Cervicalgia
M Cervicobrachial syndrome
M Cervicocranial syndrome
M53.8 Doropathies (spinal condition causing pain)
G44.3 Headache.
External Cause Codes:
V43.52x(A,D,S) Car driver injured in collision with other type car in traffic accident.
V43.62x(A,D,S) Car passenger injured in collision with other type car in traffic accident.
ADD CONCUSSION CODES

92. MEDICAL NECESSITY OF TREATMENT-CROFT STANDARDS.
The supporting chart notes should always contain a statement of medical necessity using either the Croft Guidelines of the MCA Standards of Practice.
The Croft Guidelines have 2 categories of injury;
Grade III-Moderate Injury ( limitation of range of motion, some ligamentous injury, neurological findings present):
Grade IV-Moderate to Severe Injury (limitation of range of motion, ligamentous instability, neurological findings, disc derangement):

93. MEDICAL NECESSITY-GRADE III
Grade III-Moderate Injury ( limitation of range of motion, some ligamentous injury, neurological findings present):
“Medical necessity: This treatment plan is consistent with the Croft Guidelines which have been endorsed in “Best Practices & Practice Guidelines” #NGC-7125, U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality. This is a Grade III (Moderate) injury which requires daily treatment for 2 weeks, treatment 3 times/week for 10 weeks, 2 times/week for 10 weeks, 1 time/week for another 10 weeks, 1 time a month for six months.”

94. MEDICAL NECESSITY- GRADE IV
Grade IV-Moderate to Severe Injury (limitation of range of motion, ligamentous instability, neurological findings, disc derangement):
“Medical Necessity: This treatment plan is consistent with the Croft Guidelines which have been endorsed in “Best Practices & Practice Guidelines” #NGC-7125, U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality. This is a Grade IV (Moderate to Severe) injury which requires daily treatment for 3 weeks, treatment 3 times/week for 16 weeks, 2 times/week for 12 weeks, 1 time/week for another 20 weeks and PRN care thereafter.”

95. MEDICAL NECESSITY FOR MRI.
The medical necessity for the MRI scans that have been ordered is established by the Standards of the American College of Radiology and the Agency for Healthcare Research & Quality (AHRQ) because of the presence of the following clinical signs (pick the right ones):
Radiculopathy and/or paresthesia
Neurological deficit
The severity of the injury to the ligaments and enter spinal soft tissues following trauma
Potential muscle, tendon, ligament tears;
Spinal instability
Ligamentous laxity
Failure to respond to conservative care

96. ICD 10 CODES FOR CONCUSSION
BASIC CODING FOR CONCUSSION/MILD TRAUMATIC BRAIN INJURY
S06.0x0 Concussion without loss of consciousness
S06.0x0 Concussion with loss of consciousness of 30 minutes or less
S06.0x0 Concussion with loss of consciousness of 31 to 59 minutes
S06.0x9 Concussion with loss of consciousness of unspecified duration
R Post traumatic confusion/disorientation
R Post traumatic amnesia-Anterograde
R Post traumatic amnesia-Retrograde
R Posttraumatic attention and concentration deficit
G Post-traumatic headache
R42 Post-traumatic dizziness/giddiness/vertigo
Note: Loss of consciousness and amnesia can only be accurately determined by a carefully and searching history, using the “Close your eyes and think back” technique.

97. ICD 10 CODES FOR CONCUSSION
BASIC CODING FOR CONCUSSION/MILD TRAUMATIC BRAIN INJURY
R Post-traumatic nausea and vomiting
R Balance difficulty/unsteadiness
H Post traumatic tinnitus-right ear
H Post traumatic tinnitus-left ear
G 47 Post traumatic sleep disorder
Post traumatic cognitive dysfunction- attention/concentration deficit
R Vision problem-Visuo-spatial deficit/blurred vision/double vision/convergence deficit
F Anxiety/depression
R Irritability
G47.9 Sleep disturbance
R45.1 Agitation
R25.9 Involuntary movement/dystonia

99. GOOD LUCK!! DIVE IN!!