FROM: ACAnews ~ November 2010
By Nataliya Schetchikova, PhD, ACA News Assistant Editor
For more than a century, chiropractic has largely existed in isolation from mainstream health care, evolving with its own philosophy, system of education and approach to patient care. And, like other groups that develop independently of the mainstream, the profession has created its own unique system of terminology.
The problem is, the terms—namely, preventive, supportive and maintenance care—are poorly understood by allopathic providers, patients and payers alike, which makes it difficult for DCs to communicate the value of their services and, essentially, prevents the profession from fully integrating into mainstream health care. And especially in the past decade, the difference in terminology started to cause problems in the reimbursement arena.
“The government and private payers started designing stages of chiropractic care using their own language and using this as a basis for denying care,” says Ritch Miller, DC, chairman of ACA’s Medicare Committee. “For example, Medicare doesn’t pay for maintenance care—but the definition of maintenance care is so gray that it’s left up to the claims adjusters to decide what it is, and many beneficiaries are wrongly denied care because of the interpretation of these terms,” he adds.
When claims for medically necessary chiropractic care started getting denied across multiple geographical areas and insurance plans, they were reported to the ACA’s Insurance and Managed Care (IMC) committee. “We began to see more clearly that there was significant misunderstanding, misinterpretation and misuse of the policy language we had at the time, especially in the payer industry,” says James L. Rehberger, DC, chair of the IMC Committee.
The policy language—specifically, definitions of supportive and maintenance care—was taken from the 1992 Mercy Guidelines and, in the beginning, served the profession quite well, says George McClelland, DC, former chairman of ACA’s Board of Governors. “The problem arose when insurance companies began abusing terms like ‘supportive care.’ It was dubbed maintenance care and deemed inappropriate to be billed for,” he says.
ACA’s IMC Committee attempted to make improvements to the existing language numerous times. However, after debates in the House of Delegates, it became clear that “we needed to reach a scientific multidisciplinary consensus, improve the language and make it more available,” says Dr. Rehberger.
“All other provider types do the same thing—it’s time that we did it,” adds Dr. Miller.
To conduct a proper scientific process and reach consensus on terminology describing stages of chiropractic care, ACA commissioned the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), an organization that has been accumulating evidence pertinent to chiropractic practice and developing consensus documents and literature syntheses.
From the existing literature and policy documents, CCGPP developed 15 seed statements describing the phases of chiropractic care. Then the Congress of Chiropractic State Associations and ACA were asked to nominate panelists—representing 14 states and 18 chiropractic organizations, with a broad range of philosophical perspectives—to review the statements. In addition, a nurse, a lawyer, an acupuncturist and a representative of the insurance industry were invited to join the panels to provide a multidisciplinary perspective, explains Wayne Whalen, DC, DACAN, COCSA representative to and past chairman of CCGPP and one of the authors of the consensus project.
The panelists were asked to rank the seed statements using the Likert scale— from “highly appropriate” to “highly inappropriate”— and were also “given an opportunity to provide comments, which helped to make changes to the seed statements until a consensus was attained,” explains Kara Murray, ACA’s director of federal and regulatory affairs, who managed the consensus project.
|“The value in the consensus language is to facilitate proper use within the profession, in the broader health care community, among other provider groups and government regulatory agencies, as well as in the payer industry.”|
James L. Rehberger, DC
Chairman of ACA’s Insurance
and Managed Care Committee
Defining Stages of Care
As a result of the consensus process, three stages of chiropractic care—care of acute and chronic/recurrent conditions and care for wellness—were defined, described and published in the July/August 2010 issue of JMPT.  The language explains what each type of care entails, what goals it is trying to achieve, what results can be reasonably expected, and when a specific type of care may be inappropriate. (See sidebar, titled “ Stages of Chiropractic Care, Defined ”)
For example, acute care implies that there is a specific problem for which the patient is being treated; there is also a therapeutic plan with a goal of functional improvement or pain relief, says Dr. Whalen.
“As the patients progress, they should accomplish the goals—for example, be able to bend more, have less pain or work better,” he says, adding that expecting these outcomes will affect how the DC treats the patient. “If there is an exacerbation, you don’t start all over. You do short trials of treatment, with the expectation that the patient will return to the pre-injury plateau,” he adds.
The definitions also help DCs recognize when the patient is no longer in the acute stage—and how to approach care at that point, says Ronald Farabaugh, DC, CCGPP chairman and a co-author of the consensus project. He explains that when patients reach the maximum therapeutic improvement, the doctor should attempt to terminate treatment to determine whether further care is necessary. “However, if the patient’s condition declines in the absence of care, a transition to chronic/recurrent or episodic care may be necessary to control pain, reduce the need for medications, optimize function and the ability to perform daily activities, and keep the patient employed,” he says.
Some patients, continues Dr. Farabaugh, may prefer a wellness program— which, as the new definitions emphasize, should comprise a combination of approaches, including diet/nutritional counseling, exercise and lifestyle coaching. And if the DC doesn’t provide such care, he or she may want to consider referring the patient to a colleague who does focus on those types of issues.
While the definitions provide guidelines to DCs on what specifically each stage of care entails, their goal is to improve acceptance of chiropractic in the greater health care community. “The value in the consensus language is to facilitate proper use within the profession, in the broader health care community, among other provider groups and government regulatory agencies, as well as in the payer industry,” says Dr. Rehberger.
“We hope that through various communication efforts and ACA’s Local Liaison Program, the insurance industry will have a better understanding of the levels of care that DCs utilize every day in their offices—and will improve reimbursement for the doctor and the patient,” he adds.
The published definitions will be used in discussions with the Centers for Medicare and Medicaid Services and third-party payers, says Dr. Miller. “This gives us ground to explain to payers that they are using outdated terminology and that denying medically necessary care is inappropriate.”
ACA will educate the insurance industry on the up-to-date terminology of care by sending out press releases to the insurance industry publications and working with individual insurers—and is encouraging other chiropractic organizations and colleges to embrace the new terminology, says Bobby Gibson, director of operations for ACA’s Insurance Relations Department.
Stages of Chiropractic Care, Defined |
The new terminology, established via a scientific process through a Delphi consensus panel of multidisciplinary experts, was published in the July/August 2010 issue of the Journal of Manipulative Physiological Therapeutics (JMPT). 
Care of Acute Conditions
Medically necessary care of acute conditions is care that is reasonable and necessary for the diagnosis and treatment of a patient with a health concern and for which there is a therapeutic care plan and a goal of functional improvement and/or pain relief.
The result of the care is expected to be an improvement, arrest or retardation of the patient’s condition.
Initially, the care may be more frequent, but as levels of improvement are reached, a decrease in the frequency of care is to be expected.
A patient may experience exacerbations of an acute injury/illness being treated that may clinically require an increased frequency of care for short periods of time.
A patient may also experience a recurrence of the injury/illness after a quiescence of 30 days that may require a reinstitution of care.
Care of Chronic/Recurrent Conditions
Chronic/recurrent care may be inappropriate when it interferes with other appropriate primary care or when its benefits are outweighed by its risks (psychological dependence on the physician or treatment, illness behavior or secondary gain).
Medically necessary care of recurrent/chronic conditions is care that is provided when the injury/illness is not expected to completely resolve after a treatment regimen but where continued care can reasonably be expected to result in documentable improvement for the patient.
When functional status has remained stable under care and further improvement is not expected or withdrawal of care results in documentable deterioration, additional care may be necessary for the goals of:
- supporting the patient’s highest achievable level of function
- minimizing or controlling pain
- stabilizing injured or weakened areas
- improving activities of daily living
- reducing reliance on medications
- minimizing exacerbation frequency or duration
- minimizing further disability or
- keeping the patient employed and/or active.
Care for Wellness
- Achieving wellness requires active patient participation.
Wellness is a process of achieving the best health possible, given one’s genetic makeup, by pursuing an optimal level of function.
“Optimizing levels of function” may include a combination of health care strategies such as:
- chiropractic adjustments
- manipulative therapy
- manual therapies
- diet/nutrition counseling
- lifestyle coaching.
How Can I Use the Definitions?
For these definitions to make a real difference, however, the first step is for the chiropractic profession to embrace them—and start using them.
“We hope that the terms ‘supportive’ and ‘maintenance’ care become dinosaurs and that people will use the terms ‘acute,’ ‘chronic/ recurrent’ and ‘wellness.’ Chronic patients shouldn’t be mislabeled as maintenance patients. Insurance companies cover chronic pain management; they should cover chiropractic,” says Dr. Farabaugh.
To facilitate wide acceptance of the new definitions, doctors of chiropractic can—and should—start using the definitions immediately in their documentation, communication with other providers and in their appeals and communication within the medicolegal system, such as in workers’ comp reports, says Dr. Farabaugh. “For example, be sure to record in the daily documentation when a patient transitions from acute to chronic care or to wellness care,” he explains.
In addition to the new definitions, it’s important for DCs to become familiar with the CCGPP guidelines for acute and chronic care, available at www.jmptonline.org. You can also find many papers and literature syntheses at www.ccgpp.org/documents.htm
“If you have a good understanding of the terminology and guidelines, you will have a much easier time in practice and in getting paid,” says Dr. Farabaugh.
One way providers can immediately utilize the definitions is in appealing denied claims, says Murray. “If the provider is denied care, the definitions of the stages of care support the provider’s viewpoint— giving solid evidence that the claim should be paid,” she says. And what gives these definitions greater validity is the scientific process behind them, she adds.
Dr. McClelland, who serves on the CCGPP Council, reminds DCs that they should carefully review the insurance carriers’ definitions of care before contracting with the carriers. “If you are contracted with carriers, you accept their definitions,” he says. However, doctors operating out of networks have a better chance to appeal the medical necessity of their care—provided they adhere to the definitions of care. “The terminology should have a better standing in the courts,” he says.
To aid in doctors’ appeals, ACA is planning to update its template appeals letters available at www.acatoday.org/appeals, explaining, for example, why “maintenance care” is outdated terminology and citing research to support the new definitions.
The Big Picture
In addition to using the terms “acute,” “chronic” and “wellness” care in communicating with third-party payers, it’s equally important to use them with patients and other providers, agree experts. “If we can get the profession on the same page in terms of the definitions, it will begin to [dismiss] concerns of endless, mindless chiropractic treatments,” says Dr. Whalen.
“Patients today play a much larger role in [choosing] the type of care they want,” says Leo Bronston, DC, chairman of ACA’s Integrated Practice Committee. It’s important to explain to patients the stage of care they are in, the treatment plan that the doctor has in mind, and the expected outcomes. Communicating this information to patients’ other providers will also help them understand what chiropractic care will entail, prompting them to become more open to collaborating with chiropractors, adds Dr. Bronston.
Moreover, because the consensus terminology is written in terms commonly used outside chiropractic, it serves as “an important step in the direction of bringing the chiropractic profession in a position of greater alignment with mainstream health care,” agrees Donald Murphy, DC, DACAN, clinical director of Rhode Island Spine Center and clinical assistant professor in Brown University’s Department of Community Health, Alpert Medical School.
“Being able to communicate with other providers in the health care system is essential. That means not only MDs, but also case managers for workers’ comp companies, nurses, therapists, as well as people in decision-making capacities in the government and in public health settings.”
Getting the profession on board with using the universal definitions of care will also help demonstrate chiropractic’s clinical outcomes—which is especially timely and important in the age of health care reform and electronic health records, says Dr. Bronston. “The definitions help us as a profession to understand the care we are delivering at a specific time of patient presentation, and to continually expand on the knowledge base by capturing measurable data.”
The ability to demonstrate outcomes and show the value of chiropractic care will, in turn, translate into improved reimbursement. “As we communicate to third-party payers what we do, what we are good at, what services and values we have to offer—in terms they can understand— they will see the value. If people can understand the value we bring to the health care system, they can [connect] the dollar amount with the value,” says Dr. Murphy.
“I see this consensus terminology as a huge stepping stone in tearing down barriers for patients to receive, and be reimbursed for, the chiropractic care that they choose,” says Dr. Miller.
And while ACA is integrating the new terminology into the health care system, it is up to individual doctors to do their part—learn the definitions and use them in practice. “This terminology gives ACA a solid basis to work with,” says Dr. McClelland. “But if we make our own rules, we need to play by them.”
Consensus Terminology for Stages of Care:
Acute, Chronic, Recurrent and Wellness>
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 458–463
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|“As we communicate to third-party payers what we do, what we are good at, what services and values we have to offer—in terms they can understand—they will see the value. If people can understand the value we bring to the health care system, they can [connect] the dollar amount with the value.”|
Donald Murphy, DC, DACAN
Clinical director of Rhode Island Spine Center
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