Chiropractic Assistant Procedures Program · 2020-03-14 · required to apply supportive procedures...

www.toolsofpractice.com

Presenters:

Mark A, Davini, DC, DABCNPaul Andrews, LMT, CCCA

(C) 2017 TOP EDUCATION LLC 1

Our REMOTE COMPLIANCE OFFICER ASSISTANT (RCOA) makes compliance beyond easy; simply it is a no brainer…

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TOP Ed will maintain your LEIE/OIG Exclusion list of employees.

And of course as a Privilege Member you will have access to us through the Privilege Member’s support email for all questions compliance related or not.


C.A.P.P. Course ScheduleDay One

• Registration 7:30 am• Start time 8:00 am• Break (15 min) 9:30 am

• Lunch (on your own) Noon

• Resume time 1:00 pm• Break (15 min) 3:00 pm• End 5:00 pm


C.A.P.P. Course ScheduleDay Two

• Start time 8:00 am• Break (15 min) 9:30 am

• Lunch (on your own) Noon

• Start time 1:00 pm• Break (15 min) 3:00 pm• End 5:00 pm


C.A.P.P. Course ScheduleDay Three (Oct 21)

• Start time 8:00 am• Break (15 min) 9:30 am

• Lunch (on your own) NOON

• Start time 1:00 pm• Review Start time 2:30 pm• Break (15 min) 3:30 pm

• Exam Start time 3:45 pm• Exam End Time 5:00 pm


C.A.P.P. Course Requirements

Complete 24 hours in class instructionComplete 12 hours office ExternshipPass ExaminationQualify for National Test


C.A.P.P. Externship Requirements

1. 48 documented therapies

2. Forms for documentation are in your handouts

3. Requires the doctors supervision and signature

4. Must be completed before Day Three

5. Forms must be handed in on Day Three to qualify to take the test.


C.A.P.P. Examination

Exam will be 50 multiple choice, matching, & true/false questions.

You must pass with a 77% or better.

Certificates will be emailed in about two weeks from exam date.


C.A.P.P. Course ObjectiveThis course is designed to educate the basic principles of safe and effective assistingwith common Supportive Therapies.

This course is not meant to teach the Chiropractic Assistants clinical decision making.

Operational parameters are under direction and supervision of the doctor who ordersthe service and ultimately has the final say.

This course is not meant to circumvent the doctor’s individual clinical process.


C.A.P.P. Topics

Course and CertificationHistoryMBoRC Laws, Regulations, Policies ⌫Teamwork/ProfessionalismDefinitions/Terminology Anatomy and PhysiologyTypes of CareContraindicationsDocumentationInstructionsProcedures and Protocols

⌫ indicates not on national test(C) 2017 TOP EDUCATION LLC 10

C.A.P.P. Course Supportive Therapies (most common to the chiropractic practice)

Superficial Heat focus on Hot Moist Packs

Cryotherapy focus on Cold packs

Electrical Stimulation attended & unattended

Low Level Laser Therapy

Deep Heat (diathermy) focus on Ultrasound

Mechanical Traction focus on Intersegmental

Therapeutic Exercise focus on how to assist

Neuromuscular Re-Education focus on how to assist

Vibratory Therapy


HistoryFounded on September 18, 1895

D.D. Palmer

Davenport, IA

First Patient-Harvey Lillard


CHIROPRACTIC(done by hand)

A General Laws Chapter 112, Section 89 ⌫

“Chiropractic”, the science of locating, and removing interference with the transmission or expression of nerveforce in the human body, by the correction of misalignments or subluxations of the bony articulation andadjacent structures, more especially those of the vertebra column and pelvis, for the purpose of restoring andmaintaining health. It shall exclude operative surgery, prescription or use of drugs or medicines, the practice ofobstetrics, the treatment of infectious diseases, and internal examinations whether or not diagnosticinstruments are used except that the X-ray and analytical instruments may be used solely for the purposes ofchiropractic examinations.

Nothing in this definition shall exclude the use of supportive procedures and therapy, including braces, traction,heat, cold, sound, electricity, and dietary and nutritional advice, as treatment supplemental to a chiropracticadjustment.


MA Board of Registration of Chiropractors(MBoRC) ⌫

MA Division of Professional LicensureMA Department of Consumer Affairs

Enforces:Laws, Regulations, PoliciesRegulations-4.01-4.02-4.03-4.05ScopeLimitations

Division of Professional Licensure1000 Washington Street, Suite 710

Boston MA 02118-6100617-727-3093

www.mass.gov/dpl


MBoRC Regulations ⌫

4.02: Definition and Use of Supportive Procedures and Therapies 1) For purposes of 233CMR4.00,the term "supportive procedures and therapies” means those modes of care which

may be administered, dispensed or prescribed in addition to the primary Chiropractic procedure (i.e., Chiropractic adjustments or techniques/manipulative techniques, as defined in M.G.L. c. 112, §§ 89, 94 and 97). Such supportive procedures and therapies include but are not limited to the use of braces, casting, supports, traction, thermal modalities, ultrasound, electrical modalities, hydrotherapy, myotherapy, dietary and nutritional advice and/or supplementation, and rehabilitative exercise therapy. The purpose of supportive procedures and therapies is to aid the chiropractor in assisting a patient to achieve a timely and favorable clinical outcome. A chiropractor shall not be required to apply supportive procedures and therapies in the practice of Chiropractic.

2) All decisions made by a chiropractor regarding the use of supportive procedures and therapies shall be predicated upon a properly documented clinical rationale which is consistent with present educational and practice standards. The details of all supportive procedures or therapies provided shall be recorded when performed.

3) The decision to use supportive procedures shall be based upon the clinical judgment of the chiropractor. Supportive procedures shall be used as a supplement to the primary Chiropractic procedure. However, if a chiropractor, in the reasonable exercise of his or her professional judgment, decides that a primary Chiropractic procedure is not prudent under the circumstances, he or she may properly apply any of the above supportive procedures or therapies for a reasonable time, if their use is clinically indicated and properly documented.

4) No supportive procedure shall be administered unless a duly licensed chiropractor is on the premises. (C) 2017 TOP EDUCATION LLC 15

MBoRC Regulations ⌫

4.03: Limits on Delegation of Patient Care Functions

1) A licensed chiropractor shall be responsible for all patient care provided by him or her, or by any of his or her agents or employees, and shall be responsible for any and all acts or omissions of such agents or employees.

2) A licensed chiropractor shall not delegate any clinical function for which licensure, registration or certification is required under any other applicable provision of state law or regulations to any person who does not possess the appropriate license, registration or certification required by said law or regulation.

3) A licensed chiropractor shall not delegate any of the following clinical functions to any person who is not duly registered to practice Chiropractic in the Commonwealth of Massachusetts:

(a) Performing any primary Chiropractic procedure as defined in 233 CMR 2.01: Definitions;(b) Initiating or altering any treatment plan or regimen without prior evaluation and approval by a licensed chiropractor; (c) Modifying a specific treatment procedure without the prior approval of the licensed chiropractor; (d) Interpreting clinical data or rendering opinions about such data; or (e) Rendering opinions about a patient’s current status or prognosis.


MBoRC Policy ⌫

1) The patient must be properly evaluated by the licensed chiropractor and a determination made that a supportive procedure or therapy is clinically indicated before any supportive procedure or therapy may be applied to the patient by an unlicensed assistant during the same patient visit.

2) The licensed chiropractor must make all clinical decisions regarding the type of supportive procedure or therapy to be applied, the location to which such supportive procedure or therapy will be applied, and the duration and intensity of the supportive procedure or therapy where applicable.

3) The licensed chiropractor must generally supervise the unlicensed assistant in the application of any supportive procedure or therapy by being present on the premises and readily available to provide direction and guidance to the unlicensed assistant throughout the performance of the supportive procedure or therapy.

4) The licensed chiropractor must ensure that the assistant possesses a sufficient level of education and training in the application and use of the supportive procedure or therapy. The licensed chiropractor must maintain written documentation of the education and training possessed by each office assistant regarding the proper application and use of supportive procedures and therapies.

5) The licensed chiropractor must properly report and code any supportive procedure or therapy in a manner consistent with appropriate reporting and coding requirements.

“Chiropractic Supportive Procedures & Therapies performed by Chiropractic Assistants” #09-002


MBoRC Policy ⌫

Advertising in public media shall not include the use of the terms Physical Therapy or Physiotherapy.

“Physical Therapy or Physiotherapy” April 18, 1984


Delegation / Respondent SuperiorLiability falls with the Doctor

Always stay within your training


Fraud:• There is a difference between unintended errors and intentional conduct• Routinely up-coding intentionally.• Over-utilization could lead to fraudulent charges.• Improper charges could lead to fraudulent charges.• Misrepresentation or deceit can lead to fraudulent charges.

Waste:• Over-use of services, or other practices that result in unnecessary costs. • In most cases, waste is not considered caused by reckless actions but rather the misuse of

resources.

Abuse:• Provider, contractor or member practices that are inconsistent with sound business, financial or

medical practices; and that cause unnecessary costs to the health care system.


Types of Chiropractic AssistantsAdministrative:

• Managerial/Compliance

• Reception

• Scheduling

• File Management

• Billing

• Bookkeeping

• Patient Relations


Types of Chiropractic Assistants

Clinical:

• Clinical notes

• Patient preparation

• Application of Supportive Therapies

• Discharge (check out) for the visit


Teamwork


Para-Professional

• CAs work along side the DC

• Not just a job but a profession

• Treating patients is rewarding

• Something to be proud of


General Concerns of All CAs

1) Use of Authority2) CA-Patient Relationship 3) Communication4) Boundaries5) Touching6) Patient Position/Comfort7) Hygiene8) Safety9) Consent


Use of Authority

• Relationship between the CA and the doctor has an important influence on the patient and outcome of chiropractic care

• Relationship between the CA and the patient has an important influence on the patient and outcome of chiropractic care

• Creates an atmosphere of trust and confidence

• Protects the confidential nature of the caregiver-patient relationship

• The CA should consider the patient to be their partner in the care process


CA/Patient Relationship

CAs are caregivers and therefore must be compassionate and sensitive to the patient’s needs while recognizing the importance of good communication skills.

• Provide appropriate and understandable explanations and instructions to the patient

• Recognize and respond to patient feedback and questions and concerns

• Recognize significant non-verbal signs and behaviors exhibited by the patient


Communication Regulations

• Be aware of the confidential nature of the caregiver-patient relationship

• Observe all HIPAA rules and regulations

• Ensure that only appropriate information is properly released to the doctor

• NEVER discuss patient treatment with anyone who is not authorized

• Maintain confidential treatment space


Communication Technique

Communication is the foundation of successful healthcare delivery.

1) Tell them what you are going to do

2) Tell them what you are doing

3) Tell them what you have done

4) Ask if they have any questions or concerns


Communication Verbal and Non-Verbal

• What do your clothes say

• Amiable chair

• Where are your eyes

• Voice tone “how are you doing?”

• Be mindful of how you give compliments


BoundariesRespect for boundaries is the framework of successful patient interaction.

• Attitude and demeanor • Be aware of patient apprehension • Avoid exclamatory statements and physical responses that may exacerbate patient concern • Set the tone for healing

• Leave your problems outside the office

• Do not discuss personal issues with the patient

• Keep the conversation on the care

• Be positive and optimistic

• Avoid controversial topics

• Stay focused and in present time consciousness(C) 2017 TOP EDUCATION LLC 31

Boundaries

Touching:• A patient grants you permission to enter their personal space • you must not abuse the privilege.• The power of authority is more than you imagine.

Be aware of hand placement at all times

Use as few fingers as necessary to perform function

Patients feel vulnerable when face down

Be careful your eyes may cross the line


Boundaries

If improper comments are made by the patient: Three Strike Rule:

Strike 1 Overlook/Ignore, make doctor aware Strike 2 Make clear statement of inappropriateness, make doctor awareStrike 3 You're out - leave and get Doctor

If there is improper touching: One strike Rule:You are out and get the doctor immediately!


Patient Position/Comfort

• Be careful of hair and jewelry on both patient and CA

• Proper draping

• Room temperature

• Site Integrity - Five Sense TX space

• Equipment concerns

• Emergency notification defined

• Therapy timer location


HygieneUniversal Precautions (abridged for chiropractic office)

• New standard is BBE = Bare Below the Elbow No long shirt sleeves No watch No jewelry

• Proper hand sanitation Hand washing Hand sanitizers

• Wear gloves - whenever there is a possibility of coming in contact with blood or other potentially infectious materials

• Dispose of all contaminated personal protective equipment in an appropriate container marked for bio-hazardous waste

• Proper glove removal(C) 2017 TOP EDUCATION LLC 35

SafetyDo you know what to do?

• Do you know CPR?• Do you know where the First-Aid Kit is and how to use it?• Do you know where the Fire Extinguishers and how to use them?• Do you know how to operate a Defibrillator (AED)

Automated External Defibrillator (if office has one)?• Do you know your Emergency Action Plan?• Do you know where the local emergency numbers are?• Do you know where the electrical shut off for the X-Ray is?• Do you know where the emergency exit are?


Consent

1) Consent2) Implied Consent3) Informed Consent


Confidentially Speaking…A Word about HIPAA and Compliance

• Health Insurance Portability and Accountability Act.• A Federal law enacted in 1996.• Finalized in 2013.• Enacted to safeguard Protected Health Information (PHI).

Patient Name Social Security # Address Date of Birth Clinical notes Specific Explanation of Benefits And more…

Example: Front Desk• Verifying benefits within earshot of other people• Booking diagnostics for a patient within earshot of other people• Talking about a patient within earshot of other people• JUST THE FACT A PATIENT IS A PATIENT IS CONFIDENTIAL.


DEFINITIONS / TERMINOLGY


Basic Prefixa- withoutcontra- againsthyper- increasedhypo- decreasedinfra- belowinter- betweenIntra- withinpara- besidepre- beforepost- aftersub- under/less thansupra- aboveultra- beyondosteo- bonemyo- musclearthro- jointpatho- diseaseneuro- nerve


Basic Suffix

-algia pain

-itis inflammation

-ology study of

-opathy disease


Commonly EncounteredTerms

acute sharp, severe, recentchronic long term/constantantalgic posture or gait to avoid paincavitation popping sound with osseous adjustmentsChiropractor of Record DC responsible for facility ⌫Compliance Officer person responsible for compliance programcontraindications not clinically appropriateextremity The end of something - arm or leghomeostasis balance of body systemsdiagnosis determining disease/named diseaseimpression probable diagnosisprognosis expected recoverypalpation to examine by touchinspection to examine by observationradiograph x-raystrain tendon/muscle injurysprain ligament/joint injuryhypertonicity increased muscle tonehypotonicity decreased muscle tonespasm involuntary forceful contractionsomatic external structure/framevisceral internal organstreatment procedure/protocol to effect positive change(C) 2017 TOP EDUCATION LLC 42

Commonly Encountered AbbreviationsPCP Primary Care Provider (no longer Physician)CHoR Chiropractor of Record ⌫CO Compliance OfficerMBoRC MA Board of Registration of Chiropractors ⌫Adjustment Treatment to remove/reduce subluxationsManipulation Common synonym for adjustmentCMT Medicare's term for adjustment Chiropractic Manipulative TherapyPRN Treatment as neededOTC Over the CounterROM Range of MotionNAD No Abnormalities DetectedWNL Within Normal LimitsPt. PatientCC Chief ComplaintVAS Visual Analog Scale


Commonly Encountered Abbreviations

Hx History

Sx Symptom

Ex ExaminationDx Diagnosis

Px Prognosis

Tx TreatmentRx Prescription

The “X”s


Health Care DegreesD.C. Doctor of ChiropracticM.D. Medical DoctorP.T. Physical TherapistD.P.T.A. Doctor Physical Therapy AssistantD.O. Doctor of OsteopathyD.P.M. Doctor of Podiatric MedicineD.M.D. Doctor of Dental MedicineD.D.S. Doctor of Dental SurgeryPh.D. Doctor of PhilosophyP.A. Physician AssistantN.P. Nurse PractitionerR.N. Registered NurseM.S. Masters DegreeM.A. Masters ArtO.T. Occupational TherapistB.S. Bachelor of ScienceB.A. Bachelor of Arts


?1. D.C. Doctor of Chiropractic

2. M.D. Medical Doctor

3. D.O. Doctor of Osteopathy

___________________________________

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Examination CodingEvaluation and Management – E/M

New Patient E/M Codes:99201 – Limited99202 – Expanded99203 – Detailed99204 – Comprehensive.99205 – Complex

Established Patient E/M Codes:99211 – Minimal99212 – Limited99213 – Expanded99214 – Detailed99215 – Comprehensive


Diagnosis CodingICD-10 - International Classification of Diseases 10th version:

M99.0x - Biomechanical lesions, not elsewhere classified;Includes segmental and somatic dysfunction.

M99.00 – Head RegionM99.01 – Cervical RegionM99.02 – Thoracic RegionM99.03 – Lumbar RegionM99.04 – Sacral RegionM99.05 – Pelvic Region

According to Medicare the above represent the chiropractic subluxationM99.06 – Lower extremitiesM99.07 – Upper extremitiesM99.08 – Rib CageM99.09 – Abdomen and other

Diagnosis justifying use of supportive procedures should include additional codes Dx beyond above.(C) 2017 TOP EDUCATION LLC 48

Procedure Coding

CPT - Current Procedural Terminology HCPCS - Healthcare Common Procedure Coding System

“CPT® is a registered trademark of the American Medical Association”


CPT - Procedure CodingChiropractic Manipulative Therapy:

98940 – Spinal, one to two regions98941 – Spinal, three to four regions98942 – Spinal, five regions

Modalities – Supervised:97010 – Hot or cold pack97012 – Mechanical traction97014 – Electric stimulation (unattended)97018 – Paraffin bath97024 – Diathermy

Modalities - Constant Attendance:97032 – Electric stimulation Attended (manual component)

97035 – Ultrasound97039 – Unlisted modality


CPT - Procedure Coding

Therapeutic Procedures:97110 – Therapeutic Exercises97112 – Neuromuscular Reeducation 97116 – Gait training97124 – Massage97139 – Unlisted Therapeutic Procedure97140 – Manual Therapy Techniques 99070 – Supplies and materials


CPT Coding Quirks

• If timed follow 8 minute rule/units

• Bundling v. Unbundling


Types of Chiropractic Patient Management

Disease/Condition TreatmentDisease/Condition Treatment commonly utilizes Supportive Therapies & Procedures.


Types of Chiropractic Patient Management

Health/Maintenance CareHealth/Maintenance Care does not routinely utilize Supportive Therapies


Local Coverage Determination (LCD) for Chiropractic Service Chiropractic Spinal Manipulations

LIMITATIONS ⌫

A. Maintenance Therapy

Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.


Five Aspects of Health

1) Rest

2) Exercise

3) Nutrition

4) Positive Mental Attitude

5) Sound Nervous System


Health v. Disease/Condition

Health is the optimal physical, mental, and social well-being;not simply the absence of disease/condition

Disease/Condition (lack of ease) an organ or system that has a loss of physiological balance (homeostasis) causing malfunction, i.e. functions too much or too little


Science, Art and Philosophy

All Professions:Science Anatomy and physiology of the human body.

Art Techniques of location & removing subluxations.

Philosophy The belief the body has the power to heal itself.


Chiropractor1. Doctor of Chiropractic (D.C.)

2. Chiropractor

3. Chiropractic Physician

No such words as:

Chiropractry

Chiropractics

Chiropracty



Adjustment/ManipulationChiropractic Manipulative Therapy

• Adjustment Treatment procedure to remove/reduce subluxations of the spine and associated structures

• Manipulation Common synonym for adjustment, also used by Osteopaths• CMT Medicare's term for adjustment Chiropractic Manipulative

Therapy• Mobilization General movement of joints commonly performed by P.T.s



Adjustment Techniques

1. Osseous - Manual - commonly popping

2. Mechanical -Drop Tables - specialized table

3. Instrument -Impact Devices - specialized tools

4. Soft tissue -Pressure Protocols - with breathing assist

Above may be utilized with varied amounts of force from low to high.



1. Misaligned vertebra

2. Causing nerve interference

3. Resulting in altered function

Altered function means too much or too little, i.e. dis-ease/condition


Five Components of a Subluxation

1.Joint movement too much or too little- altered function

2.Muscle movement too much or too little - altered function

3.Hard tissue Wear & Tear too much or too little - altered function

4.Soft tissue Wear & Tear too much or too little - altered function

5.Nerve interference too much or too little – altered function

Chiropractic Adjustments treat all five components.

Supportive Therapies assist the Chiropractic Adjustment in treating one or more of the five components of a subluxation.

If Supportive Therapies are extensively utilized without a Chiropractic Adjustment it approaches Physical Therapy.


Nervous System

• Master Controller of all other aspects of the body

• Function is to maintain balance (homeostasis)

• Interference results in too much or too little function


Basic Anatomy & Physiology


Anatomical Position

Reference point for anatomical sides and sites(C) 2017 TOP EDUCATION LLC 69

Positions and DirectionsAnterior/Ventral toward the front

Posterior/Dorsal toward the back

Medial toward the middle

Lateral toward the side

Coronal toward the head

Caudal toward the bottom

Superior above

Inferior below

Proximal Closer to the trunk or midline

Distal Further away from the trunk or midline

Erect standing

Supine lying flat face up

Prone lying flat face down

Side Posture / Side lying on the side(C) 2017 TOP EDUCATION LLC 70

Positions and DirectionsExtension (spine) moving backwardsFlexion (spine) moving forwardLateral flexion (spine) moving sidewaysRotation (spine) turningMedial Rotation turning in towards midlineLateral Rotation turning away from midlineAdduction brings limb medially (adding to body)Abduction moves a limb laterally (carry away)Circumduction Cone combination flexion, extension, adduction, abduction togetherInversion turn inEversion turn outElevation movement superiorlyDepression movement inferiorly








Body Planes


Body Planes

A - Median (not medial) divides left and right equally

B - Sagittal divides left and right where ever

C - Frontal divides front from back

D - Transverse divides upper from lower

E - Proximal Closer to the trunk or midline

F - Distal Further away from the trunk or midline


11 Major Organ Systems1. Nervous: Master controller.

Maintains homeostasis. Computer of the body andWiring connecting brain to the body and the body to the brain.

2. Skeletal: Support.Movement. Protection, Production of RBCs. Storage of minerals. Structure of the body.Hormone regulation (glucose regulation).

3. Muscular: Creates movement.4. Circulatory: Transports substances throughout body via arteries, veins, and heart.5. Lymphatic: Transports lymph fluid throughout the body.

Removes excess fluid. Fights infection.


11 Major Organ Systems

6. Respiratory: Brings Oxygen to the blood.Removes Carbon Dioxide.

7. Skin/Integumentary: Protects, regulates, and senses environment (largest).8. Endocrine: Secretes and regulates hormones.9. Digestive: Breaks down food.

Absorbs nutrients. Removes solid waste.

10. Urinary: Cleans and balances the blood chemistry. Removes liquid waste.

11. Reproductive: Produces and facilitates procreation.


Skeletal Anatomy

•206 bones in the human body = Rigid Connective Tissue

•Cartilage= Flexible Connective tissue lining joints





SpineSpinal Column 31+ bony segments of the spineVertebra bony segment of the spinal columnVertebrae plural of vertebra

Occiput base of the skullAtlas first cervical vertebra Axis second cervical vertebra Cervical neck areaThoracic (dorsal) mid back areaLumbar low back areaSacrum base of spinal columnCoccyx tailbone

Lordosis anterior curve of the spineKyphosis posterior curve of the spineScoliosis lateral curve of the spine



Spine Area # of Segments Designation

Cervical 7 C1 to C7

Thoracic 12 T1 to T12

Lumbar 5 L1 to L5

Sacral fused 5 S1 to S5

Coccyx 2 to 4

______________________________________________

Total 31 to 33


Spine Side:

Right LeftBilateral

Levels:upper middle lowerC1 to C2 C3 to C5 C6 to C7T1 to T4 T5 to T8 T9 to T12L1 to L2 L3 to L4 L5 to S1

Sacroiliac (SI) Joints: Joint between the sacrum and ilia


Vertebral Anatomy1) Processes (projection of bone)

o Spinous Processo Transverse Process

2) Vertebral Body

3) Facet joints

4) Intervertebral Disc (k)o Nucleus Pulposus Gelatin Centero Annulus Fibrosis Outer rings

5) Foramen (openings)o Spinal Canalo Inter-vertebral Foramen (IVF)


Vertebral Anatomy


Vertebral Anatomy


Vertebral Anatomy


Vertebral Anatomy

Herniated Disc = (Displacement of disc material beyond the interspace.)

• Protruded (contained), (slipped)• Extruded (non-contained), (ruptured)

The term “prolapse” has been use to refer to either without specifying which one and therefore is too ambiguous.

Best to avoid use of the term prolapse altogether.


Vertebral Anatomy


Vertebral Anatomy


Motor Unit2 vertebrae - 1 disc - 2 nerves left and right


Muscle AnatomyTypes:

1) Cardiac/Heart2) Smooth/Organ3) Striated/Skeletal

• Supportive Therapies treat the striated (skeletal) type.

• Skeletal Muscles move the body.

• Simply, there are 2 places that muscle connect: 1) Origin – Source generally fixed position2) Insertion - Attachment point – part being moved.

• Most muscles are deep to other muscles.

• Muscles are usually named after look or location.


Muscle Anatomy

Prime Mover: muscle that carriers out an action

Synergist: muscle that supports the prime mover

Antagonist: muscle that performs the opposite action of the prime mover and synergist muscles


Muscle AnatomyPrime Mover Antagonist

FlexionExtension


Muscle Anatomy

Spinal Muscles to Remember:

• SCM Sternocleidomastoid = Side to front of neck• Trapezius Triangular shaped muscle over the neck and midback• Rhomboids Muscle connecting shoulder blade to the vertebrae• Paraspinals Muscles along side the spine.

Connect to vertebrae to vertebrae (and ribs). Help protect disc and maintain upright posture.

• Latissimus Dorsi Major mover of the shoulder.• Quadratus Lumborum Top of Ilium to transverse processes of lumbar vertebrae.• Gluteals Buttock muscles. Assist with rising from sitting and/or stairs.


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy

Extremity Muscles to Remember:

• Deltoid Arm abduction• Bicep Forearm flexion• Triceps Forearm extension• Hamstring Extends hip and/or flexes knee• Quadriceps Extensors of the knee• Gastrocnemius Flexing leg at the knee and/or plantar (foot) flexion


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


Muscle Anatomy


X-Ray Safety


X-Ray Safety

1. In MA CAs cannot take X-Rays.2. Primary importance is patient safety.3. All female patient must be asked:

“Is there a chance that they are pregnant?”4. Proper Informed Consent.5. Use lead shielding to cover areas not needing exposure.6. Proper instruction to patient, e.g. remove all metal.7. Proper room protection.8. Proper use of exposure badges.9. Equipment properly maintained.


Phases of Condition Treatment1.Relief acute/highest pain / least function

most therapies/most frequent

2.Therapeutic repair/less pain/improved function

decreased therapies/decreased frequency

3.Rehabilitative healing/little to no pain/most function

minimal to no modalities, some therapeutic procedure/less frequent

4.Supportive chronic management/MMI

no therapies/least frequentPhase of Condition Treatment is defined by the DC and may determine if the

services are bundled or unbundled.(C) 2017 TOP EDUCATION LLC 120

Phases of Condition Treatment

Phase of Condition Treatment is defined by the DC.

• Is the goal/rationale non-duplicative?

• Is it a Modality or Therapeutic Procedure?

• If Modality is it Supervised or Constant Attendance?

• Is it timed based?


CAs need to Know!

• Contraindications

• Instructions

• Documentation requirements

• Location of First-Aid kit

• Emergency Procedures

• Your Patient

• X-Ray Safety(C) 2017 TOP EDUCATION LLC 122

ContraindicationsCommon to All Therapies

Absolute: Common for all. e.g. EMS over pace maker

Relative: Specific to the individual patient/condition/past reaction,e.g. ultrasound on pregnant patient


ContraindicationsCommon to All Therapies

Application of a therapy against contraindications may sometimes apply. This is referred to as “off-label” use and requires a higher level of knowledge and expertise and carries a greater risk. CAs should never perform Supportive Therapies against contraindications.

The DC must perform this service.

For purposes of this course the common contraindications for all are:

1. Sensitivity to agent2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Never mate with the eight!(C) 2017 TOP EDUCATION LLC 124

DocumentationCommon to All Therapies

S.O.A.P.• Subjective Patient presented information• Objective Doctor derived information• Assessment Conclusions from above• Plan Treatment specifics /goals/expectations recommendations


CA Supportive Therapy Notes are in the “P” Section.

L - Location side, area, levelI - Instructions/Informed Consent pt. instructed & consented to TxS - Settings time, intensity, frequency etc.T - Time actual stop and start timeD - Discharge Status “pt. tolerated tx w/o incident”C - CA Identification signature or initials-legible

Use of standard abbreviations are allowed.

Use of unique in-office abbreviations should not be use.

DocumentationCommon to All Therapies



InstructionsCommon to All Therapies

Instructions: P.E.A.C.E. of mind

P rotocol inform patient of protocol

E xperience inform patient what they will feel

A lterations inform patient about changes in feeling

C omfort inform patient that it should always be comfortable

E mergency inform patient of emergency protocol bell/buzzer, shut-off switch and/or procedure


Vitals

Gender (M) (F): Report male or female or Unspecified

Height (Ht): Report in inches.Normal based on age and genderInches (in.) or Centimeters (CM) “

Weight (Wt): Report in pounds.Normal based on age, gender, and Ht. Pounds (lbs.)


Vitals

Respiration: Report in breaths per minute.Report rhythm.Normal based on age.Adult at rest = 12 to 18 BPMBreathes per minute /regular

Temperature (temp): Report in degrees Fahrenheit or Celsius.Normal at rest = 98.6 ° F°F or °C

Pulse/Heart Rate: Report beats per minute.

Normal based on age and condition.Adult at rest = 60 to 100 bpmbeats per minute (bpm)


Vitals

Blood Pressure (BP): Report systolic/diastolic in millimeters of mercury. (mmHg) Report in even numbers.Normal based on age.Normal at rest = 118/78 mm Hg to 126/84 mm Hg


Review Practical


Two Classes of Supportive Therapies

1) Modalities (gadgets): Purpose to improve sign or symptom.• Supervised

No Direct One-on-One patient contact required Not a timed procedure

• Constant Attendance Requires Direct One-on-One patient contact Timed

2) Therapeutic Procedure: Purpose to improve function• Requires Direct One-on-One patient contact• Timed


Cryotherapy (Cold)Use of Cryotherapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Relief Phase without documentation of special circumstances

Goal competes with other “modalities”

(except for decreasing circulation)

Modality supervised

Not Direct One-on-One

Not time based

97010 – Application of a modality to 1 or more areas; hot or cold packs


Cryotherapy (Cold)

Cold Pack, Immersion and Vapor Sprays

Wet & Dry Packs most common

Dry used by most practitioners


Cryotherapy (Cold)

Effects:

Decreases local circulation (only therapy that does this)

Decreases muscle tension

Decreases inflammation and/or edema

Decreases pain

Pre-adjustment relaxation


Cryotherapy (Cold)Contraindications:

Never mate with the eight!1. Sensitivity to Cryotherapy2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to Cryotherapy:Fair or sensitive skin

Circulatory disorders


Cryotherapy (Cold)Procedure & Protocol:

Review file for any contraindications

Check equipment (if ice pack, check for leaks)

Check temperature

Patient position: ◦ Expose area to be treated ◦ Inspect area for any rashes, wounds etc.


Cryotherapy (Cold)

Set-up:

Observe area to be treated

Determine size of pack

If wet technique is used; rinse towel under cool water and ring out.

Wrap Cold Pack with dry or wet towel.


Cryotherapy (Cold)Instructions: P.E.A.C.E. of mind


Experience inform patient that they will feel cold

A lterations inform patient that the temperature will decrease


E mergency inform patient as to location of emergency bell/buzzer and if uncomfortable to ring bell/buzzer or call out ASAP


Cryotherapy (Cold)Application:

State instructionPlace pack on towelsQuestion comfort levelSet timer Return and check area after 3 to 5 minutesAdd towels if neededAfter designated time remove packs, place towels in contact with patient in laundryInspect treated areaDocument response, time, location


Cryotherapy (Cold)Monitoring Procedure:

Have an emergency protocol, e.g. bell or buzzer for patient to ring if needed

Check patient after 3 to 5 minutes then every 5 to 7 thereafter


Cryotherapy (Cold)Negative Response/Reaction:

Stop Procedure If:If skin appears frosted remove pack ASAP

If skin appears excessively red or blistering remove pack ASAP

Patient complaints of a burning sensation

Patient complains of increased pain

Get the doctor


Cryotherapy (Cold)

Nevers:

Never have patient lie on packs

Never place on patient without a towel

Never use against contraindications


Cryotherapy (Cold)CA Documentation:


L ocation to include side, level

I nstructions Informed Consent

S ettings

T ime start and end time

D ischarge Status post therapy

C A identification


Sample NoteCryotherapy

“Plan” section:

“Patient informed of Cryotherapy and consented to treatment.”

Bilateral Mid to Lower Lumbar

2 dry towel layer

Time 1:30p-1:45p

“Patient tolerated treatment w/o incident.”

Mary Jones, CA


Superficial Heat

Use of Superficial Heat (especially HMP) Therapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances

Rationale/goal competes with other “modalities”

Modality supervised

Not time based


97010 – Application of a modality to 1 or more areas; hot or cold pack


Superficial HeatSources of Superficial Heat:

Conduction direct contact skin to heat, e.g. HMP, Heating Pads

Convection travels through affected medium, e.g. Whirlpool

Radiation travels through unaffected medium, e.g. infra-red lamps

All types of Superficial Heat carry the risk of skin burns.


Superficial Heat

Most frequent form used is Conduction, e.g. Hot Moist Packs (HMP), Heating Pads, Whirlpool and Paraffin Baths

Of those, the most common is Hot Moist Packs (HMP)

HMP = routinely from a hydrocolator


Superficial HeatEffects:

Increases local circulation



Promotes healing

Decreases pain



Superficial HeatContraindications:

Never mate with the eight!1. Sensitivity to Superficial Heat2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to Superficial Heat:

Acute severe inflammation

Fair or sensitive skin

Patients with fever


Superficial HeatProcedure & Protocol:


Check equipment

Check temperature, should be between 125 and 155 degrees

Patient Position

Expose / Inspect area to be treated

Packs to be placed on patient.

Inspect area for any rashes, wounds etc.(C) 2017 TOP EDUCATION LLC 152

Superficial Heat

Set-up:

Observe area to be treated

Determine size of pack and towel layers needed based on patient and conditions• minimum 6 towel layers• Holders generally count for 4 layers (check manufacturer)

• if holder is used add 2 towel layers to equal 6 total• If only towels use cross method


Superficial Heat



E xperience inform patient they will feel warmth

A lterations inform patient temperature will increase


E mergency inform patient as to location of emergency bell/buzzer and if uncomfortable to ring bell/buzzer or call out ASAP


Superficial HeatApplication:

State instructionsRemove Hot Pack from hydroc away from patientPlace pack in holder / on towel layersPlace on patientQuestion comfort levelSet timerReturn and check area after 3 to 5 minutesAdd towels if neededAfter designated time remove packs, replace in unit, and place towels in contact with patient in laundryInspect treated areaDocument response, time, location


Superficial HeatMonitoring Procedure:

Have an emergency bell or buzzer for patient to ring

Check patient after 3 to 5 minutes then every 5 to 7 thereafter


Superficial HeatNegative Response/Reaction:

Stop Procedure If

If skin appears excessively red or blistering remove pack ASAP

Patient complaints of a burning sensation


Get the doctor


Superficial HeatNevers:

Never have patient lay on packs

Never use less than 6 layers

If a Heating Pad never fold



Superficial HeatCA Documentation:




S ettings


D ischarge Status post Therapy

C A identification


Sample NoteSuperficial Heat

“Plan” section:

“Patient. informed of MHP therapy and consented to treatment.”

Bilateral Mid to Lower Lumbar6 towel layersTime 1:30p-1:45p“Patient tolerated treatment w/o incident.”

Mary Jones, CA


Body TemperatureProcedure for Taking Oral Temperature:

May be taken in multiple location-oral, rectal*, axillary, temporal, auricular.May use thermometer that needs to be inserted or hand held instrument that measure radiate heat off skin surfaces.Most common location is oral or forehead.1. Clean hands.2. Remove thermometer from storage container.3. Clean thermometer4. Shake down to lowest mark5. Place under tongue, leave in place for minimum of 3 minutes.6. Remove and record number.7. Re-clean, shake down and replace in storage container.8. If Temperature is greater than 98.6 ° F, inform doctor if not WNL.

* = NOT IN MA(C) 2017 TOP EDUCATION LLC 161

Electrical Stimulation (ES)Attended:

Manual

Typically hand held instrument

Modality, Constant Attendance

Timed based

Areas treated and time on them must vary

97032 – Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes


Electrical Stimulation (ES)TYPES:

Low Volt Increased skin resistance, superficial

High Volt Less skin resistance, deep

Interferential Medium frequency, broad areas of TX

Iontophoresis Chemical ions into superficial tissue

T.E.N.S. Transcutaneous Electrical Nerve Stimulation

A.C. Alternating Current

D.C. Direct (galvanic) Current


Electrical Stimulation (ES)Many variables affect the way tissue responds:

VoltageFrequencyType of current-AC/DCPulsed RateRefractory periodDuration of stimulationIntensity of stimulationNumber of padsPlacement of padsPolarity of the pads


Electrical Stimulation (ES)

Good News

DC determines the intention & settings of the ES.

The procedures for all ES are similar.


Electrical Stimulation (ES)Effects:




Passive exercise

Reduces trigger points

Promotes nerve function

Decreases pain

Pre-adjustment relaxation(C) 2017 TOP EDUCATION LLC 166

Combo Units

Electric Stimulation

Infrared Light Therapy

Ultrasound Therapy



Electrical Stimulation (ES)Contraindications:

Never mate with the eight!1.Sensitivity to ES2.Pregnancy3.Children under 104.Area of numbness or decreased sensation5.Open wounds, rashes, burns6.Over heart, head / brain7.Over internal or external implanted devices8.Cancer

Specific to ES:Over metallic implants

Front of neck (carotid sinus reflex)

Varicosities/Phlebitis

Over menstruating uterus



Use of ES Therapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.

Rational/goal competes with other “modalities”



There are 2 ways to administer ES:1. Attended2. Unattended

Some insurance companies only reimburse for the attended.


Electrical Stimulation (ES)Unattended:

Modality Supervised

Not time based

most carriers code 97014 – electric stimulation (unattended)

HCPCS G0283 –Electric stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of careMedicare requires G0283 to make the service a patient responsibility

Aetna / United Healthcare requires G0283 for payment consideration



Procedure & Protocol:Review file for any contraindications

Check equipment; all controls to zero with unit on

Select pads

Check Connections

Patient position to expose area to be treated

Inspect area for any rashes, wounds etc.


Electrical Stimulation (ES)Set-up:

Many office have routine settings for the most common areas treated. Should not use metal tables Review file for any contraindications Set current per instructions from DCSet frequency per instructions from DCSet rate of contractions per instructions from DCIf pulsed set width of pulse per instructions from DCSet contraction time per instruction of DCSet ramp up time if availableMake sure skin is clean and free of debrisExcessive hair may interfere with EMSApply pads; location per instruction from DC




Protocol inform patient of protocol

Experience inform patient that they will feel a tingling feeling

inform patient they may feel muscles move

describe and/or show patient anticipated movement of muscle

Alteration inform patient that the intensity will slowly increase

Comfort inform patient that it should always be comfortable

Emergency inform patient not to touch the control panelinform patient as to location of emergency bell/buzzer or kill switch and if uncomfortable to ring bell or call out ASAP


Electrical Stimulation (ES)Application:

State instructions Device should be on, if not turn on device with intensity to zeroPlace pads on patient (keep wires parallel, leads pointing towards machine)Slowly increase intensityQuestion comfort level at each changeIncrease to tolerance and then back down or to pre-instructed levelSet timerReinforce location of emergency bell/buzzer Return and check area after 3 to 4 minutesAdjust settings in neededAfter designated time turn off deviceRemove pads and replace all equipment and wiresInspect treated areaDocument response, time, intensity, location and settings


Electrical Stimulation (ES)Monitoring Procedure:

Have an emergency bell or buzzer for patient to ring if needed

Check patient after 3 to 4 minutes then every 5 minutes thereafter


Electrical Stimulation (ES)Negative Response/Reaction:

Stop Procedure If

If skin appears excessively red or blistering get the doctor, ASAP (do not remove the pads)Patient complaints of a burning sensationPatient complains of increased painPatient complains of electrical shock feeling

Get the doctor


Electrical Stimulation (ES)Nevers:

Never have patient lay on pads

Never place over old scars (decreased sensation)

Never place over areas with loss of feeling

Never place over moles, warts

Never place over metal implants

Never place over heart or across chest A to P

Never place over infections of open wounds

Never place over hemorrhaging areas

Never place over front of neck (carotid sinus reflex) or throat

Never use to treat varicosities

Never use to treat phlebitis

Never place over low back or abdomen of pregnant patient

Never place over menstruating uterus

Never place over internal or external implanted electronic devices

Never place on head

Never use against contraindications(C) 2017 TOP EDUCATION LLC 178

Electrical Stimulation (ES)CA Documentation:




S ettings


D ischarge Status post therapy)

C A identification


Sample Note ES

“Plan” section:

“Patient. informed of EMS therapy and consented to treatment.”

Left Mid Thoracic

Low Volt-2 Pad-Ramped-Pulsed-20 contraction/minutes

(if defined-example office MT protocol 1)

To Patient comfort 8/10

Time 1:30p-1:45p


Mary Jones, CA


Blood Pressure

Blood Pressure (BP): Pressure in arteries only (not veins).

Systolic: Maximum pressure - heart beat/contraction.Diastolic: Minimum pressure - heart relaxes between beats.

Hypertension: High blood pressure.

Hypotension: Low blood pressure.BP Cuff: Inflatable portion of instrument.

Sphygmomanometer: Meter portion of instrument in mm Hg.Stethoscope: Listening device that magnifies sound.


Blood Pressure

Procedure for Taking Blood PressureManual

Instruments required:

1. Blood Pressure Cuff

2. Stethoscope


Blood PressureProcedure for Taking Manual Blood Pressure:May be taken on any extremity, commonly right arm.

1. Patient should be at rest, seated, and arm to be tested is supported (commonly right).

2. Extend arm with slight bend, but keep relaxed.

3. Open valve on pump bulb.

4. Place BP cuff one inch above bend of elbow.

5. Snug cuff tight enough so 2 finger tips can fit under the top of the cuff.

6. Place earpieces end of stethoscope in ears.

7. Place diaphragm end of stethoscope (disc shaped) over anterior bend of elbow.

8. Close valve on pump bulb.

9. Inflate to 30 millimeters above reported normal.

10. Release valve in cuff slowly - 2 millimeters (lines) per second.

11. Listen for the first beat you hear, take note of number. THIS IS THE SYSTOLIC NUMBER.

12. Continue listening until beating stops take note of number. THIS IS THE DIASTOLIC NUMBER.

13. If interrupted and need to start over, first deflate cuff all the way.

14. Do not re-inflated half filled cuff.

15. If BP is outside normal range inform doctor


Deep Heat (Diathermy)

Types:

1. Short Wave light 2. Microwave light3. Ultrasonic sound

All have high frequency currents

All force cells to vibrate and create heat by friction

More vibration, more heat

All Deep Heat techniques carry a risk of deep burns


Deep Heat (Diathermy)Many variables affect the way tissue responds:

Wavelength

Intensity/wattage

Placement of device

Technique of application

Dosage


Deep Heat (Diathermy)Effects:

Local deep heat on the treated tissue



Micro massage/vibratory effect

Increases cell activity


Decreases pain




Each device has generally the same contraindications.

The following list is a combination of all devices.

Use of diathermy for one or more of the below reasons should be performed by the DC.


Deep Heat (Diathermy)Contraindications:

Never mate with the eight!1.Sensitivity to Diathermy2.Pregnancy3.Children under 104.Area of numbness or decreased sensation5.Open wounds, rashes, burns6.Over heart, head / brain7.Over internal or external implanted devices8.Cancer

Specific to Diathermy: Over attached hearing aids Over fractures Over metallic implants, dental, orthopedic Over adhesive strapping Over casts Over eyes Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB Varicosities/Phlebitis Over menstruating uterus



Use of Diathermy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances




There are different Modality codes for each type of deep heat some are Supervised and others Constant Attendance.

Unattended:• Microwave Diathermy• Modality, Supervised• Not Direct One-on-One• Not time based• 97024 – diathermy (eg, microwave)



Short Wave and Microwave techniques require a higher level of understanding and therefore carry a higher risk and will not be reviewed in this class.

Background, procedures and protocols are fundamentally the same but need to be specifically reviewed by DC

Most common form utilized in the chiropractic office is attended Ultrasound

Unattended ultrasound is rare and generally not yet accepted by most insurers.


Ultrasound Therapy

Attended:

Ultrasound

Hand held probe


Timed based

97035 – ultrasound, each 15 minutes


Ultrasound TherapyProcedure & Protocol specific to Ultrasound:


Check equipment; all controls off

Select transducer head size based on anatomical part

Check Connections


Procedure & Protocol specific to Ultrasound:

Determine method:• Immersion• Direct contact through conducting (coupling agent) medium• Maximize heat use a glycerin based agent• Maximize vibratory effect use water based agents

◦ Medium should be room temperature or cool(Contrary to common thought)

◦ When cool this enhances heat removal from surface• Determine settings per DC instructions

• Continuous mode generates more heat

• Pulsed enhances vibratory effects

Best to use more than less

Ultrasound Therapy


Ultrasound TherapySet up:

Table should not be metal

Patient Position

Expose area to be treated

Inspect area for any rashes, wounds etc.

Make sure skin is clean and free of debris

Review file for any contraindications and/or with patient

Set power mode (wattage) per instructions from DC

Set timer per instructions from DC(C) 2017 TOP EDUCATION LLC 195

Ultrasound Therapy



E xperience inform patient they will feel warmth

A lterations inform patient temperature will increase

C omfort inform patient that it should always be comfortableE mergency inform patient as to location of emergency bell/buzzer and if

uncomfortable to ring bell or call out ASAP


Application:State instructions Turn on device with intensity to zero, wattage as instructedSpread medium on area to be treatedPress start (this should start timer also), keep transducer head flat Do not expose transducer head to air while running (maycrack the crystal insides) Move transducer head in an up and down, side to side or circular motion over area spreading medium

◦ Do not cross the spine◦ Do not apply over boney prominences◦ Do not apply over areas with metal implants◦ Do not hold in one place

Slowly increase intensity to instructed level; continuously move transducer head over area being treatedOverlap 50% with each stroke of transducer headQuestion comfort level at each changeQuestion what they are feelingAdjust settings as neededAfter designated time turn off device, clean head and replace to holderClean and inspect treated areaDocument response, time, intensity, location and settings

Ultrasound Therapy


Ultrasound Therapy

Monitoring Procedure:

Observe area being treated during process

Question comfort level regularly during process


Ultrasound TherapyNegative Response/Reaction:

Stop Procedure IfIf skin appears excessively red or blisteringPatient complaints of a burning sensationPatient complains of loss of feelingPatient complains of increased pain

Get the doctor


Ultrasound TherapyNevers:

Never cross the spineNever apply over boney prominencesNever apply over areas with metal implantsNever stop moving US headNever place over areas with loss of feelingNever place over moles, wartsNever place over heart or across chest A to PNever place over infections of open woundsNever place over hemorrhaging areasNever place over front of neck (carotid sinus reflex) or throatNever use over occlusive vascular conditionsNever place abdomen of pregnant patientNever place over menstruating uterusNever place over internal or external implanted electronic devicesNever place on head, eyes or earsNever use against contraindications


Deep Heat (Diathermy) / Ultrasound

CA Documentation:




S ettings



C A identification


Sample NoteUltrasound

“Plan” section:

“Patient. informed of US therapy and consented to treatment.”

Left-Mid to Lower Lumbar

Continuous Wave 1.0 watts

Time 1:30p-1:45p


Mary Jones, CA


Pulse/Heart Rate

Procedure for Taking Pulse/Heart Rate:

1. May be taken anywhere there is a pulse, e.g. radial, axillary, carotid.

2. Most common location is the radial pulse of the right arm.3. Use your index and middle fingers.

4. Do not use your Thumb.

5. Place two fingers over the artery to be monitored.6. Counts the number of beats in one minute.

7. Record number in bpm.

8. If Pulse/Heart Rate is outside normal range inform doctor.



Traction (IST)

Unattended:

Mechanical

Modality supervised


Not time based

97012 - traction, mechanical

Some carriers considers Intersegmental traction (IST) experimental and will not reimburse for it under any circumstances.


Traction

Traction is the drawing or pulling apart sections or parts of the body

Traction can be applied by hand, weights, stretch cords, springs, mechanical devices or gravity


TractionTypes:

• Manual performed with hands and requires doctor• Mechanical Involves a “gadget”

Forms:• Axial along the spine• Intersegmental between motor units

Methods:• Static/Continuous steady pulling• Intermittent off and on pulling

Specialized Variations:• Flexion Distraction considered an adjusting technique performed by the DC.

Treatment utilizing table that flexes with hand contact.• Computerized Axial Decompression: traction utilizing a computer controlled traction device.• Gravity Inversion: traction utilizing frame device inverting patient against gravity.


TractionEffects:


Stimulates proprioceptive response in joints and tissue

Stretches adhesions

Increases circulation

Decompresses IVF

Promotes disc hydration

Decreases pain



TractionContraindications:

Never mate with the eight!1. Sensitivity to Traction2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to Traction:Severe joint instability

Uncontrolled hypertension (high blood pressure)

In combination with adhesive strapping

Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB


Traction

Use of traction throughout the Therapeutic and initial part of the Rehabilitative Phases is acceptable however rationale as an unbundled service generally does not exceed up to the middle of the Rehabilitative Phase without documentation of special circumstances



TractionMost common form of traction in the chiropractic office is Intersegmental Traction (IST)

Rollers are hourglass shaped


Traction (IST)

Procedure & Protocol:Review file for any contraindications and/or with patientReview file for height and weightCheck equipment; all controls offIdentify area to be treated per DCDetermine settings of device or weight to be used per DC instructions IST set length of traction rollers per DC instructions IST set height of traction rollers per DC instructions IST if applicable set vibration or no vibration per DC instructions

Many offices have routine settings for the most common areas treated in a chiropractic office.


Traction (IST)


Traction (IST)

Set up:

Table should be off

Patient Position

Supine for IST

Question/ Inspect area for any rashes, wounds etc.

Make sure area is free of debris


Traction (IST)

Instructions: P.E.A.C.E. of mind:

P rotocol inform patient of protocol.E xperience inform patient they will feel rolling under the spine and to not press

into rollersA lterations inform patient that the degree of rolling will increase

and the rollers will travel up and down the spine.C omfort inform patient that it should always be comfortable

E mergency inform patient if uncomfortable to call out


Traction (IST)Application:

State instructionsTurn on device with intensity to lowest settingSlowly increase intensity Question comfort level at each changeIncrease to instructed levelStart timerQuestion what they are feelingAdjust settings if neededAfter designated time turn off deviceQuestion/Inspect treated areaIf your machine turns off automatically let patient know.Document response, time, intensity, location and settings


Traction (IST)Monitoring Procedure:

Have an emergency bell or buzzer for patient to ring if needed

Check patient after 3 minutes then every 5 minutes thereafter


Traction (IST)Negative Response/Reaction:

Stop Procedure IfPatient complains of loss of feeling


Get the doctor


Traction (IST)Nevers:

Never perform over areas with loss of feeling

Never perform over infections of open wounds

Never Perform over recent stitches

Never perform over hemorrhaging areas

Never perform over fractures

Never perform on pregnant patients

Never place prone



Traction (IST)

CA Documentation:




S ettings



C A identification


Sample NoteIST

“Plan” section:

“Patient informed of traction therapy and consented to treatment.”

Bilateral-Upper Thoracic to lower Lumbar

Height 5/8, no vibration

Time 1:30p-1:45p


Mary Jones, CA


Respiration

Procedure for Observing Respiration:1. Note rise and fall of patient’s chest.

2. Count the number of rising chest observations for one minute.

3. Record number.

4. Observe if respiration has a regular rhythm.

5. Record number in breaths per minute – breaths/min/regular.

6. If rate and/or rhythm are outside normal range inform doctor.


Low Level Laser Therapy (LLLT)Use of LLLT throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.Goal competes with other “modalities”


There is no CPT code for this service. If using CPT code for this procedure you use the unlisted modality code 97039 with an explanation describing type and time. Payment is at the discretion of the insurance carrier

You can use HCPCS CODE S8948 - Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

Some carriers considers it experimental and will not reimburse for it under any circumstances.


Low Level Laser Therapy (LLLT)Laser Phototherapy

L.A.S.E.R. Light Amplification by Stimulated Emission of Radiation

Synonymous Names

Cold Laser

Non-Thermal Laser


Low Level Laser Therapy (LLLT)

Class 1 no risk to tissue during normal operationClass 1M No known hazards to eye or skin unless

collecting optics are usedClass 2a Visible Lasers not intended for viewing. No known hazards up to a maximum

exposure time of 1000 secondsClass 2 & 2b no risk to tissue…low level, bar scannersClass 3a Similar to Class 2 (except collecting optics can be used)Class 3R no known risk to tissue…medium level (replaced Class 3a)Class 3B risk to retina…medium level…LLLTClass 4 increased risk to tissue…high level

LLLT is a Class 3b laser registered with the FDA since 2002.



LLLT is in the infra-red spectrum with low wattage beam.

It is not the same as infra-red heat lamps


Low Level Laser Therapy (LLLT)Effects:



Reduces trigger points

Promotes increase cell function and energy

Decreases pain


Low Level Laser Therapy (LLLT)Contraindications:

Never mate with the eight!1. Sensitivity to LLLT2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to LLLT: Direct exposure to the eyes Over thyroid Patients on light sensitive medications or immune

suppressant drugs Patients with heart disease



Phase of Condition Treatment:

Use of LLLT throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.


Low Level Laser Therapy (LLLT)There are 2 ways to utilize LLLT

1. Modality for injured area

2. Acupuncture point stimulation


Low Level Laser Therapy (LLLT)Procedure & Protocol:


Check equipment; all controls off

Check Connections

Patient positionExpose area to be treated Inspect area for any rashes, wounds etc.



Set-up:Set voltage per instructions from DCSet frequency per instructions from DCSet intensity per instructions from DCIf separate; set width of beam per instructions from DCSet timeMake sure skin is clean and free of debrisLaser emitter may be hand held or mounted on a stand





E xperience inform patient that they should not feel anything however on occasion some patients feel a slight warmth or coolness

A lterations inform patient to let you know about any changes




Low Level Laser Therapy (LLLT)Application:

State instructions

Place protective goggles on all in the room (including you)

Set the appropriate levels

Start therapy

Question comfort level

Set timer

After designated time turn off device

Inspect treated area

Document response, time, intensity, location and settings


Low Level Laser Therapy (LLLT)Monitoring procedure:

Question patient throughout treatment


Low Level Laser Therapy (LLLT)Negative Response/Reaction:

Stop Procedure If

If skin appears excessively red or blisteringPatient complaints of a burning sensation

Patient complains of increased painGet the doctor


Low Level Laser Therapy (LLLT)Nevers:

Never perform without safety goggles on all in the roomNever place over moles, wartsNever place over metal implantsNever over heartNever place over infections of open woundsNever place over hemorrhaging areasNever place over abdomen of pregnant patientNever place over internal or external implanted electronic devicesNever place on head (except TMJ)Never use against contraindications


Low Level Laser Therapy (LLLT)CA Documentation:




S ettings



C A identification(C) 2017 TOP EDUCATION LLC 238

Sample NoteLLLT

“Plan” section:

“Patient. informed of LLLT therapy and consented to treatment.”

Right Upper Trap medial and lateral-hand held

Time 1:30p-1:45p


Mary Jones, CA


Posture Analysis

• Posture may be analyzed from the Anterior, Posterior, or laterally.

• Normal depends on viewpoint.

Posterior: Level head-level shoulders-level pelvis-gluteal fold in line with center of occiput-spinous processes-evenly center between knees and feet (pointing anterior).

Anterior: Level eyes-level shoulders-level pelvis-nose in line umbilicus (belly button)-evenly center between knees and feet (pointing anterior).

Laterally: Mid ear-mid shoulder-mid-hip—mid knee-mid ankle.


Posture Analysis


Posture Analysis

Procedure for Analyzing Posterior Posture:• Unless otherwise instructed, posture will be viewed from the posterior and laterally on the right.

• Unless otherwise instructed report in terms of high side.

• Have the patient stand with hands by their side, feet, shoulder with and pointing forward.

1) Observe if head is level. If not what side is high? Record high side.

2) Observe if shoulders are level. If not what side is high? Record high side.

3) Observe if pelvis is level. If not what side is high? Record high side.

Hints: for pelvis, look at skin folds, garment line.


Posture AnalysisProcedure for Analyzing Lateral Posture:

• Unless otherwise instructed report observed part anterior or posterior to normal.• Right Lateral: Have patient stand with back to observer; hand by their side, feet shoulder

with and pointing forward.• Step to the patient’s right side.• Imagine line from mid-ear-shoulder-hip-knee-ankle• Observe if ear is split by that line. If not is it anterior or posterior to that line. Record.• Observe if shoulder is split by that line. If not is it anterior or posterior to that line.

Record.• Observe if hip is split by that line. If not is it anterior or posterior to that line. Record.• Observe if knee is split by that line. If not is ts anterior or posterior to that line. Record.• Observe if ankle is split by that line. If not is it anterior or posterior to that line. Record


Posture Analysis


Posture Analysis


Therapeutic Procedures

Most common Therapeutic Procedures:

1. Therapeutic Exercise (TE)

2. Neuromuscular Re-Education (NMR)



•Purpose is an “attempt to improve function” and are not symptom driven

•Unlike Modalities clinical need must be defined in terms of decreased function.

•There must be a metric to gauge progress, i.e. Outcome Assessments, Exam, History



Remember, when treating injuries from MVAs the goal is pre-injury.

If, as a result of a MVA, Therapeutic Procedures are indicated,an attempt at defining pre-injury level of function should be part of the protocol

The documented medical necessity for the service(s), short and long term goals and metrics are expressed in terms that define the patient’s condition and progress in comparison to

pre-injury status or need that otherwise would not allow for recovery.


Therapeutic Exercise

Direct One-on-OnRequire skilled serviceTimed basedRequire specific functional goals expressed by metricsMust be performed by a Licensed Physician or Other Qualified Healthcare Professional 97110



Methods:WeightsAerobics with or without equipmentResistance cordsIsometric exercisesStretching maneuvers



Effects:

Develop strength

Develop endurance

Increase ranges of motion

Increase flexibility

When performing this service the intent/rationale must be quantified as one of the above on any given date.


Neuromuscular Re-Education

Direct One-on-OnRequire skilled serviceTimed basedRequire specific functional goals expressed by metricsMust be performed by a Licensed Physician or Other Qualified Healthcare Professional 97112



Methods:Proprioceptive Neuromuscular Facilitation (PNF)

Balance boards and discs

Feldenkreis

Neuro-Developmental Technique (NDT)

Hemispheric rehab

Bobath’sTechnique



Effects:

Improve balanceImprove coordinationImprove postureIncrease kinesthetic sense

(bodies sense of it own placement in space)

When performing this service the intent/rationale must be quantified as one of the above on any given date.


Therapeutic ExerciseNeuromuscular Re-Education

Contraindications: Never mate with the eight!

1. Sensitivity to TE & NMR2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to TE & NMR:

Severe joint instability Uncontrolled hypertension (high blood pressure) Aneurysms Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB



Procedure & Protocol:

Review file for any contraindications and/or with patient

Review file for Height and Weight

Review BP, respiration, pulse

Check equipment if applicable

Identify area and goal to be treated per DC

Determine settings of device or weight to be used per DC instructions



Set up:

All equipment in a safe and neutral position

Patient position

Determined by procedure per DC instructions

Make sure area is free of debris

Place patient in appropriate position per instructions from DC




P rotocol inform patient of protocol, breathing, reps, posture etc. demonstrate exercise/protocol make sure they are clear on what to do

E xperience inform patient what they will feel

A lterations inform patient about changes in feeling

C omfort inform patient that it should always be comfortableE mergency inform patient that if uncomfortable to call out ASAP



Application:

State instructions

Patient begins

Question comfort level during each set

Document response, time, intensity, location and settings



Monitoring Procedure:

Monitor breathing and pulse

Monitor posture, position

Monitor time, reps, weight

F.A.S.T.



F.A.S.T. (T)Face Drooping: Does one side of the face droop or is it numb? Ask the person to smile.

Arm Weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?

Speech Difficulty: Is speech slurred, are they unable to speak, or are they hard to understand? Ask the person to repeat a simple sentence, like "the sky is blue." Is the sentence repeated correctly?

Time to call 9-1-1: If the person shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get them to the hospital immediately

Tongue:



Negative Response/Reaction: (Assisting the doctor)

Stop Procedure IfPatient complains of loss of feeling


Patient complains of shortness of breath

Patient complains of dizziness

Patient complains of weakness; especially one sided



Nevers:Never perform on pregnant patients not use to exercise




CA Documentation:

CA Supportive Therapy Notes are in the “P” Section.L ocation to include side, levelI nstructions Informed Consent

S ettings




Sample NoteTE & NMR

“Plan” section:

“Patient informed of Ther. Ex. and consented to treatment.”

Lumbar Endurance protocol-treadmill…..

4 miles per hour

Time 1:30p-1:45p


Mary Jones, CA


Vibration Therapy

Use of Vibratory Therapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.

Rationale/Goal competes with other “modalities”

Modality/Constant Attendance

There is no code for this service

The code has been deleted. Any billing for this procedure must use the unlisted modality code 97039 with an explanation describing rationale, type and time

Payment is at the discretion of the insurance carrier

Vasopneumatic Device


Vibration Therapy

G-5, Jeanie RubRapid Release


Vibration Therapy

Effects:


Superficial adhesions


Trigger Points reduction

Decreases pain



Vibration TherapyContraindications:

Never mate with the eight!1. Sensitivity to vibration2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to Vibration:

Acute local inflammation

Fair or sensitive skin

Circulatory disorders


Vibration TherapyProcedure & Protocol:

• Review file for any contraindications

• Check equipment:

◦ Check connections/wires

◦ Patient position/away from wires

◦ Expose area to be treated

◦ Inspect area for rashes, bruising and wounds, etc.


Vibration TherapySet-up:

Attach proper head to device (if applicable)

Inspect head for cleanliness and integrity

Be careful of long hair on patients


Vibration Therapy



E xperience inform patient that they will feel vibration

A lterations inform patient that the vibration will increase




Vibration TherapyApplication:

State instructionsCover area with towelPlace device on areaStart at lowest levelProceed to desired intensityQuestion comfort levelAfter designated time remove towel and place in laundryInspect treated areaDocument


Vibration TherapyMonitoring Procedure:

Question comfort:

If painful or itchy periodically throughout treatment


Vibration TherapyNegative Response/Reaction:

Stop Procedure If

If skin appears excessively red discontinue

If patient reports increased discomfort or pain

Get the doctor


Vibration Therapy

Nevers:

Never have patient lie on vibratory device

Never place on patient without a towel(s)

Never bill using code “vasopneumatic device” 97016



Vibration TherapyCA Documentation:




S ettings




SAMPLE NOTEVIBRATION

“Plan” section:

“Patient informed of Vibratory Therapy and consented to treatment.”

Bilateral Mid to Lower Lumbar

Medium intensity

Time 1:30p-1:45p


Mary Jones, CA


For Example:Massage - CPT 97124 Manual Therapy Techniques - CPT 97140

Therapeutic Procedures that encompasses services that are part of licensed professions, i.e. Chiropractors, Medical Doctors, Osteopathic Doctors, Physical Therapists, Massage Therapist.

Level of education is beyond the scope of this course.

One-on-One Services as defined by CPT



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