What is a Subluxation?
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Hi, I’m Dr. Mark Studin. First. I’d like to thank ChiroSecure for giving me the forum to share this with you. But today I am so excited to share something with you that. Pretty much, one of the most difficult and uncomfortable things for most chiropractors to do in their office and that’s documentation. And today is about documentation may easy. Let’s go to the slides. Now, when we look at documentation and we understand. What we need to do. We want to make it easy. We want to make it easy. However, documentation is about not just putting words on a piece of paper so you could get paid. Yeah. It’s about reimbursement, but it’s about compliance of reputation and what do we put in there and how can we cut corners and what could we do and how do we do it? I’ve learned all these things in school and here I am now. Do I still have to do these things? We’re going to go through and explain this in intimate detail. Now the first thing you need to do, if you want to get paid, you need to get unique to stay current. And that’s important. If you want to stay off the radar screen of the carriers, you’ve got to stay current in coding and coding is critical and there are companies out there like HJ. Who have incredible coding platforms that give you the updates. Some of the EMR systems also give you updates as you go along and inform you. But I happen to this particular company because it consistently they’re spot on and they give you all of the updates what’s added and what’s deleted. You have to know in this particular. In 2022, there were 159 additions, 32 deletions and 20 revisions. And some have to do with us. For instance, you can’t use low back pain. So if you use here’s one where blue cross blue shield correctly deny the claim because the doctor used N 54.5 low back. You can’t use that. You have to use M 54.51 vertebra genic, low back pain. So you must update your diagnosis and your documentation so that your is have a valid, clinically approved code. And that’s really important. We’re going to talk about pain codes in just a moment about fairway codes. But the other thing that you have to be concerned of is that you’re accurate. I get it that some carriers don’t want to pay and it’s a fight, but when you’re the reason you’re not getting paid, that’s unacceptable to me. That just means you’re not on top of your game. Now. Here’s the important about documenting thoroughly and accurately. It’s about your reputation. It’s about your reputation. You talk about getting paid and compliance, your reputation equals referrals. So who’s looking at your reports and the primary cares and the specialist lawyers, they’re all looking at your ports and they’re judging you. If you don’t have the right codes is a moment ago that I just shared that. You are not going to get paid. And that’s really important, unique to prevent audits and prevent lawsuits. And if you want to use your documentation, as you should to get new patients, it’s the easy button because your documentation is often your calling card. It’s your business card. Here’s what I do. And your referral sources are actually going to be looking at and reading it. But you see your documentation is your sheet. To the carrier sword, because what you put on papers are going to prevent lawsuits. Mr. Rico could come knocking on your door. We’ll talk about that later on. We’ll talk about SIU special investigative units and listen, this isn’t chicken little, the sky is falling. It’s really. If you were being sued by a cat carrier, how many people would you tell the answer is nobody. If you got 20 new patients the past two weeks, you would tell every single person, because us chiropractors have it, have a attendance. Of all these sharing, all the good things in sometimes embellishing on it, but not sharing the bad things. Oh, I got I’m being investigated by SIU special investigative. I just got a loss. No one tells you any of those things. I’m the person that got. G Dr. Mark, what do I do? I just got sued. Who do I call? What do I do? Because I’m like the father confessor, how do I get out of it? And my answer at that point in time is you have to hire a criminal defense lawyer and yes, a criminal defense lawyer, because the lawsuit of you’re being charged with fraud. So the goal is folks not to scare you. And I’m not saying it’s happening to you, but it happens more than you think. And by the way, your malpractice carrier. Will not cover you for fraud. They’re not going to cover you for fraud. You’re on your own. So you have to be careful. Will they cover you in a retrospective audit? Yeah, sure. They will. ChiroSecure does that, but a retrospective audit is different than a fraud allegation in a lawsuit. Our documentation is your shield to their. Now here’s lazy shortcut folks, travel cards, the number one kiss of death, the carriers have already told me. And I have incredible relationships with attorneys for multiple carriers. And they’ve told me travel cards are the easiest way for them to win miss elements. You’re supposed to put family history, social history, review of systems. Past medical history, all these things, those are missed elements. You bill for time in 2021 to 2022, you inflame your time. I had someone who actually went to prison because he was putting down too much time and the carriers actually put someone, they hired an investment. Who sit outside of his office with a camera, with the time clock to see how much time that person was in there. This is about seven or eight years ago, but doctors sometimes are so stupid that in a 24 hour period, they’re billing for 27 hours worth of services. Duh, how silly can you get or stupid at that? My next favorite one is incident to. My support staff is doing this incident too. They’re putting therapies on and statements that they’re not allowed. They’re doing certain levels of evaluations where they’re not allowed to make clinical judgments. They are pushing buttons to take x-rays when they are not allowed. Incident to support staff. You must be careful. And then in order to have your staff do that, you need approval from your state board. And if you do not have it in writing, Hey, hi, this is Dr. Student is my, it is marrying my staff allowed to do a leg link check on Solomon or put stem on or heat or Ultracet. Yeah, sure. You know what? That’s worth zero. It has to be in writing, shoot him an email. This email is to confirm Mrs. Jones, what you just said from the board about what Mary could do, or please respond with, says that, yes, this is you need a response where you have to have something in writing, because if it doesn’t, if it’s not in writing it, doesn’t. You have to protect yourself. Cookie cutter reports, the carriers right now, their mantra, the carriers, in world war II D day was the was decision day. That was, and they called the D day. They gave it a name. The carriers named their campaigns also, and it’s called fraud. So the carriers have a fraud for profit scheme and cookie cutter reports are called predetermined treatment plans. And that is a big no from them right now because these folks who run results of those things, I just mentioned. And by the way, I’m a little bit demented. This is my book club reading list. Three out of four of my kids are attorneys. So I got into search engines called Lexus nexus and Westlaw, and I go on with them and they pull up things. I look at all these different federal complaints. Is there Rico cases? This one’s a 20 20, 20, 20, 20 18, 20 16, 20 18. And this is 2020. So we’re talking relative new stuff. And this is Florida, New York. Seattle Maryland. This is Michigan. So they’re pretty indiscriminate of where they go and look, but they’re going after people who are not playing by the rules and the carriers have changed their plans of going after the big offices and big money to smaller offices, because you can’t afford the good lawyers and you roll over easier and they get paid quicker. So here’s the other thing. And what, and by the way, I know this supposed to be how to make your documentation easier, but I want to make it compliant that easier. I’ll get to the easier in a minute, oh, I’m only going to build a 9, 9 2 0 1 or a 2 0 2. Look at this 9, 9 2 0 1, 2 0 2 and 2 0 3. There’s a Rico case because the standards weren’t followed. It doesn’t matter what code you, bill it down, coding it. Doesn’t get you off their radar. And it doesn’t and there is no radar screen anymore. It’s an algorithm. Their computers are very good at looking at different things. So it doesn’t matter what you bill, you just have to do it right in what you build for now. When we look at reputation and compliance exposure, you see the screen, you can hardly read these documents. These documents were faxed and or scan that email. Is this the type of work you send to your, when lawyers request information or you’re sending stuff to a co-training physician, even a carrier wants information. If this is the stuff you said that they can’t read it, guess what folks your reputation is trash. You’re below that if a PT, not even on par with the PT, because PTs do damn good though. And they’re re they’re illegible. So you’ve got to ensure that your reputation is intact. And if you add the Cate versus delegate, if you give your staff member stuff to do, and this is the kind of crack they’re sending. Guess what your practice is going to be in trouble because it’s going to reflect that everything has to be perfect and you no longer pay careful attention to your detail. You have to pay exquisite attention to detail because your competition is making you irrelevant. And then the marketplace, if you want your market share, you have to not only compete, but make your competition irrelevant. Now. Fancy terms. I just use that has nothing to do with chiropractic you’re in the business world market share marketplace, irrelevant. All of these things are applicable to chiropractic because we don’t run mom and pop businesses. According to the SBA, we’re a small business, which goes from one to $40 million. That’s where we should be in where you see. So when we look at documents, this is what they should look like when they go out. Just like you’re seeing here, and guess what folks you need to initial every single intake form everyone. And if you’re doing it electronically, work with your EMR system, show that you initial that you will electronically initial each page or signed. So this way, invalidates that you’ve reviewed these things, because if you don’t initially, how do we know that you’ve reviewed it? We done. And certain things are allowable to be used, but you have to have verification. You looked at it. So that’s one easy way to help make you more Bulletproof. But by the way, if you’re using paper and not an EMR system and not tight, you’re in the 1970s and eighties you’re irrelevant by the way. You’re very early. To your referral sources and that’s very important and you’ll be treated like that. You’ll be treated like that with the carriers. Also that grammar matters looking at this one. Here we go. This is one EMR system. The questionnaires was reviewing annotated. The last hundred doctors diagnosed with this rent annotated meant 98. Didn’t know what it means. It means to note on. So if you don’t initiate. Or make a note on your intake form. You can just perjured yourself. Perjury is punishable by jail, fine. And their loss of license here. Here’s another one. Kylie was positioned Kylie doctor you’re on the witness stand. Do you have a relationship with Kylie? Do you smoke a cigarette when you’re done and look in there? I am back them in the eyelashes, I’m being obnoxious, but that’s the. If it renders an air of prejudice by using the patient’s familiar first name Ms. Jones, Ms. Smith, never first named Kylie here’s. Another one and airbag did not. Kylie was positioned and airbag did not. This is all in first person. You never wrote anywhere. Ms. Jones reported the fall. This is what doctor did you watch that accident happen or did you watch Ms. Jones fall? Here’s here’s another really good one. The patient’s vehicle may or may have not been towed from the scene. How could you, think about junior high school kids do better and this isn’t doctor’s actual report N may or may not have been at the scene and then prescribed the medication. That’s it just full colon. Th no sentence and one medication, it wasn’t, it was an Oxy or was it an aspirin? All these things grammar matters. Now, by the way, this report I got from a lawyer because this report was circulated a bar association meeting with the doctor’s name on it. That person’s reputation was destroyed because they were a joke. They were a joke even. And here’s another one mechanism of injuries under the second. Patient complaints at the time. What does that have to do with mechanism of injury? And this is an initial E and M C subjective objective. Why is this in so low format right away? You’re telling every referral source that you’re functioning as a physical therapist, S O a P an ENM evaluation and management, new patient Evalyn. A reeval is not done in soap. That’s not a compliance issue. These are reputation issues and folks, by the way, if you want to learn, I’m not done. I’m just throwing this in here. If you want to learn more, call me here’s my email. If you want to take CE courses on how to do this, and I know I’ve only got another few minutes today, but if you want three, four hour course on documentation, maybe. Good to teach doctors.com. You can take courses there. If you want help getting personal injury cases, just give me a jingle or go to teach cars.com. I’m more than happy to help you. Here’s another good one. This is an actual new patient intake. This is a handwritten note. This one is going by the way, it was built at a 9 9 2 0 4. One patient is fraud because you don’t have all the things that are needed in an oh four. There’s no time in here we go. No tests ordered or reviewed, and this is what’s needed in an oh four, no interpretation of outside tests, no past medical history, no family social, no review of systems. This one patient constitute fraud. If it’s many patients. Then the carrier can remand this over to a federal prosecutor or they can take, go to their attorneys and drop a Rico suit on you under the organized racketeering act for using a paper instrument in a systematized manner to the fraud of a financial institution call the insurance companies. So you’ve got to be really careful. You got to understand what’s going on. It’s easy. And you were taught in school. Everything you learned in chiropractic. It was accurate. I teach them three chiropractic colleges. I can tell you will never get out of clinic with documentation like this. You’ll never ever get out of clinic. This folks is fraud, plain and simple. You’re collecting money for work. You didn’t do you need to. Go and Google it. Look it up. If you’re not sure. Get a coach, I’m more than happy. Get someone else. I don’t care. You’ve got to be compliant. And that’s critical. Those throwaway diagnoses codes we use myalgia low back pain and neck pain. We call those throwaway codes. You should never use these diagnoses. They’re very low level and myalgia. What’s called. Low back pain. What’s causing it neck pain. What’s called you don’t. You’re not saying anything. So you’ve got to get into what’s causing these things and that’s what you should be diagnosing, not using the throwaway codes. And the other thing is, and I’m bouncing back and forth. I should have put the throwaway because after this, when you’re looking at. As of January 20, 21, the ENM codes are time-based as well as elements. You have a choice. So you need to look at the coding and by the way, you never use a 2 0 1 or a 2, 1, 1, they don’t exist for a doctor. A chiropractor may never use a 2 0 1 or a two on one. And there are time to face, but when you get into your re-evaluations, you’re often down coding and cheating yourself because the 2 0 3, which is 30 to 40, 40 minute. Is the same as a 2, 1 4. Now that’s 30 to 40 to 39 minutes. So basically it’s the same time, but a higher level of code in a re-evaluation. So you’ve got to watch your coding and you don’t want to downcode to stay off the radar screen. We showed you that before that’s absurd. You just have to be accurate and you have to document. You’re also documented for encounter time. Let me read this. This is now encountering. Not face-to-face this includes reviewing patient’s documentation before you see them. Additionally, this includes reviewing the intake after patient face-to-face time. This includes reviewing x-rays and MRIs. It does not include your staff’s time. Now, if they do the original load PQRST that doesn’t include that. So it also mandates you with. Every intake document. If you’re going to be billing for time, when you don’t see the patient, you count the time you reviewed the work your staff did, and that does not need, okay. This is incorrect by the way, you cannot count the time. Your staff did. Oh, I apologize. You can’t the time you reviewed. The work, your staff did that’s allowable, and that does not need to be in front of the patient. It’s also why you initial the intake forms. Now, by the way, these changes are per Sam Collins from HTML. Sam’s incredible by the way. And if you want someone to help me with coding, he’s wonderful. Doing a thorough clinical evaluation without cutting any corners should take every DC a minimum of 30 minutes. I can not see. And I’ve done this a lot. How you could do an appropriate chiropractic intake by doing family history, social history, review of systems, past medical history, vitals, ortho, neuro motor sensory plan recommendations, reviewing them. In less than 30 minutes, it’s almost impossible. You gotta be cutting corners and that’s where you’re going to get in trouble. Be careful. Now let’s look at consistency because reputation is the key. This is on ENM, which is evaluation and management. This is. And you’re going to see this in every ortho, neuro neurosurgeon pain management and 30% of chiropractors. Cause I do compliance reviews just about every day of my life in the last 17 years introduction, including age accident, incident history, case history, initial history, past medical history, family, social allergies, review of systems functional. Vitals exam diagnosis, prognosis test order referrals, goals, treatment corner. You will see this at every medical specialist in the industry. This is what I see in 70% of the Kairos offices. And not necessarily in this order. Starting, I reviewed one yesterday, past medical history. They don’t want it to duties under duress. Then it went to and then cause they’re pandering to the plaintiff’s attorney inspection and vitals Rangers. Spinal palpation, neurological limited, by the way, complaints down in number seven, treatments done today, which does not belong in initial evaluation. And number of visits patient is going to be seeing 12 times. You don’t do that. That is against the rules patient. According to the federal register CMS patients shall be reevaluated every 30 days cutting corners equal non-compliance. I want to know what the penalties are. Your license, potentially a freedom. If you do it in a big enough way, in a bad enough way, but these are things what you’re on. Good, which will get you not paid, which will get you no referrals and can cost you all these things. It’s just easier to do it right the first time. And it’s actually simple. It’s actually just as easy to do it, is it is to do it wrong. You just have to be willing to open your eyes and say, oh, I can do that. And every single person, I go through this with which again is a lot who are here, which is at least 70%. And by the way, I could say that I could say unequivocally right now that 95% of every chiropractor in the next. Oh, who’s not working with me is committing some level of insurance fraud by cutting corners and being deficient in documentation. And I can only say that by looking at all the compliance reviews that I do on a daily basis and out of those 95%, 90% of those doctors. There are compliance issues within two weeks, 90%, because there are such simple solutions to help you get there regardless of your EMR, regardless of how you do it. So you’ve got to take a hard look at what you’re doing. Docs that’s really important. Now, if you’re using an EMR, which you should be using macros, there are mandatory, healthy shortcuts. They’re pretending. Okay. Pre templated, such as Mrs. Jones presented with a history of a car crash with cervical, a little more pain I ordered and reviewed her x-rays today’s office visit for new patient evaluation manager is building two or three due to the key components of a detailed history examination and medical decision-making of low complexity. This qualifies for a 9, 9, 2 or three. You see what I did when I send the symptom to the carrier, I’m actually telling them what I think. I’m telling them why you are not going to investigate me. It prevents lawsuits. I’m going to, I’m not going to pass it audit. I’m not going to need one. I’m going to be preventing it. And this is how you earn more money. You meet their issues. You just go to the obvious. Here’s what they’re looking for. Telling them why this met their needs. They’re not going to audit me and I’m going to probably send in my evaluation on the first visit. So why they gonna audit me if they already have my evaluation and the rationale. And that’s the key. See, your staff also becomes a C S I agent. Okay. Crime scene investigator on the initial visit. This is where it starts folks on the initial visit. Were they that your staff says Mrs. Jones paid. We’re always curious about how you heard about our office. Okay. Who told you about, doctors, students? Oh, I heard it from my friend, Sally all, and then always say something nice about that person. Now, if it’s an attorney, do not put that lawyer’s name on your intake forms anywhere, which says referred by Mr. Smith lawyer, because that could be an ethical issue for the. Keep a separate spreadsheet away from the chart, nothing to do with it, which says, where are your referral sources, where your referrals came from? Which referral sources? Because it could jam them up and get a problem. Now, the next thing I always do is I always get information over the phone. My staff gets information. Oh, could you give us. Mrs. Jones. Before you come in, I’d like to pre-fill out some paperwork for you now, who does it like pre filled out paperwork at a doctor’s office. Everyone likes it. Why do you do that? Because Mrs. Jones, we’re going to save you a lot of time. What’s in it for them now what’s in it for you. I need your insurance information. Could you please give me the insurance for make sure your insurance card? If it’s a car accident Mrs. Jones, would you mind taking a minute and just going in the glove box in your car and get your insurance card? All the way in a moment, I don’t mind and get the information before they come into your office, you call the carrier and qualify insurance. They might’ve been to 16 doctors for you and have no med pay benefits. There are no fault might’ve been rescinded. They might not have paid their insurance policy. Do you want to start with a patient where you know, they’re not going to have any money available on that? No hell no. Now if they don’t have any money on a case and they have a lawyer, can I have the name of your lawyer please? And you contact the attorney. What’s the liability, what’s the policy limits of this case? How does the liability look? All these different things you need to learn before you take this patient in, because the next thing you’re going to be treating the patient for free. And then the other thing you have to do is ensure you have the right documentation for my client. I had an attorney sit and write a two page document, assignment of rights, assignment of benefits and liens all in one document, which has all the language. These doctors, my doctors need my doctor on average, their take home pay after taxes goes up 61% the first year because they have the right intake forms, which gives them the ability to collect their money. If you don’t have those things, you’re in trouble. You need to think first you need to gather the information. Do you have a police report now? Why do you want that? You want a police report? Because a lot of information is in there about insurance policies. The other person, if it’s third party, not that you have claimed. Okay. But all of these things are important to have if they’re in an accident and again, you want their insurance. If it’s Medicare, if it’s managed care, if it’s Medicaid, whatever it is, you need to qualify a front, make sure it’s paid. Make sure there are benefits. So really by the way, if it is a car accident, can you bring a photo of the damage? You want to have that on record because later on, you’re going to need that at some level. So these are the things you need. It all starts. On the first phone call and by the way, your staff had best give good telephone. And I mean that sincerely perky happy. I used to put a mirror in front of the right behind the telephone, a mirror. And I told my staff, when you on the phone, you look at that mirror and I want to see a smile on your face because that’s smart. I was going to come through in your voice and they laughed at me and they said, you know what? Dr. Mark, after some time, what a difference that. Patients, and it just changed the whole tone of the office. So there are so many little things that you can do that you could do to make not only documentation of. But use it as a strong source of referrals and listen, folks, I love doing this stuff. It’s so much fun for me. If you have questions, please call me. Here’s my cell number. Here’s my, my, my email address. If you want to take continuing education courses, go to teach doctors.com. There’s a ton of really good quality educator. Talk by the best chiropractors in the industry, Harvard trainer, radiologist, Albert Einstein trained vascular neurologist. The litany of people teaching are the best of the best, not just in our chiropractic industry, but in healthcare, from all over the country, actually all over the globe. So we’ve got people international, just a lot of fun. He need any coaching on personal injury, go to teach cars.com and Alyssa. I’d like to get to thank ChiroSecure so much. For giving me the opportunity to share this platform. Next week, we have an attorney, Mike Miscoe, he’s wonderful. I strongly urge you to to be here and you’re already asked to say, and for that folks, I’d like to say thank you and just have a great day. Bye-bye.