Independent Medical Examination and Peer Review Dr. Donald Morris, D.C

IndependentMedical Examination

and Peer ReviewDr. Donald Morris, D.C.

Introduction to Chiropractic

● Vocabulary● Abbreviations● Adjustive techniques● Laws and rules

Adjustive techniques

Diversified, manual adjustment

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Lumbar manual adjustmentside posture

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Cervical manual adjustment

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● Laws and Rules● CPT Codes commonly misused● 15-Minute Rule● Fraud

Independent Medical Examination (IME)

Photograph of Florida Driver License. Obvious discrepancies.

Other cultures will show multiple names not on the policy. That will help in records. For

example some Haitians use first, second, third, etc names interchangeably!

Accident History

Notice discrepancies between versions, remember some differences are usual but

question passengers not listed in crash report

Past Medical History

The person enters into a crash with medical conditions that will be treated, some of which

were not caused by, or were only partially caused by the crash.

Immediate Medical Attention

ER, was there diagnostic imaging? Level of care.Diagnostic imaging.

Health history included in ER records may be missing in clinic records.

Subsequent Medical Attention

Any other medical care corroborating or contradicting treating clinic records.

Chiropractic and others at the Treating Clinic

● Clinical records listThis will be read in court.

Occupational History

Critically important to understanding recovery and conditions that are not related to the crash.

Loss of work days may not corroborate with other accounts, and it may be made clear that loss due to other than injuries is responsible.

Social History

May differ from that taken elsewhere. Medically pertinent regarding daily activity. Example: new parent or grandparent taking on care of grandchild.

Diagnostic Imaging

Deny charges for films if ER records were not requested. A duplicate set of films is redundant and constitutes unnecessary exposure and cost. If hospital films are available usually the quality is superior and the radiation exposure less for the same films.

Diagnostic testsexperimental OK, but not for billing

http://wiregrasschiropractor.com/services/chiropractic/pulstar-adjusting/

Current Complaints

Do complaints match claim and diagnosis?

Low back and right knee pain matches lumbosacral sprain/strain and knee strain or contusion.

This is probably not lumbosacral radiculopathy (radiating from the spinal nerves).

Physical Examination – Positive Findings

Positive straight leg raise or positive anything is nonsense if not explained.

+SLR on R at 30 degrees producing LBP rad to post R knee would indicate sciatic nerve irritation when tractioned, possibly from a disc lesion.

Physical Examination – Negative Findings

Ordinarily most tests will be within normal limits. Examinations with mainly positive findings are suspect in all but the worst cases. One reason for “positive tests” is testing too soon after a crash. Most of the tests are impossible at first.

Physical Examination cont.

The ER physician does not do Spurling's test, turning the head to where the cervical nerves would be pinched, then hitting the top of the head with his fist to see if a radiating pain is produced. Initial chiropractic exams often show this test.

Almost all the orthopedic tests will seem to be “positive” the first few days after a crash when generalized stiffness and soreness is present.

Opinion

Is further treatment by chiropractic medicine reasonable, related, and necessary?

Opinion regarding past treatments and billing issues require peer review.

Peer Review

Purpose

Standards

Guidelines, Common sense and the 'smell test' or the 'mirror test'

Red Flags: Computerized documentation created by randomization programs

Indications of fraud.

SOAP Notes

Case Management: Real, believable person or cookie cutter?

Diagnostic Testing: Does the test influence diagnosis, prognosis or treatment plan?

CPT Code Misuse

CPT Codes Commonly Misused: Massage 97124 represented as 97140 Manual Therapy, and 97112 Neuromuscular Re-Education, 97110 Therapeutic Exercise misrepresented as 97112 Neuromuscular Red-Education. Other codes.

15-Minute Unit. When six units are billed for services, taking a total of one hour..actually only a total of four units can be allowed. Practitioners are taught by salesmen otherwise.

Durable Medical Equipment

Durable medical equipment may be added out of proportion to need and may not be clinically managed. TENS, LSO and home pneumatic traction are examples. The above units are sometimes available to the clinic for one-tenth of the price billed to the patient. Proper workups, followup and documentation is rarely present, but the profit margin is tempting for the clinic.

Electrodes and fitting are often unbundled.

Fraud

Dangerous people involved.

Funds other enterprises.

Staged crashes – accidents happen and real injuries occur, fatality to innocent

Fraud cont.

Fraud/abuse more likely with computerized systems - all patients look alike. Pattern repeats. May be beautiful note if only one day is read, but pattern is obvious. Randomization is computerized.

Large patient mills have multiple doctors, therapists, patients, locations. Treatments are cookie cutter.

Real notes make sense. Notes tell the story of injury and recovery.

Fraud - Runners

Runners are illegal. Transnational crime groups. Close knit communities are networked. Runners go to social activities to recruit patients.

Q & A