Medical Necessity of a Whiplash: Post Slip and Fall
By Nancy Martin-Molina, DC, QME, MBA, CCSPI recently called a patient's auto insurance company to see if my returning walk-in patient had any medical pay included in his policy. His car had been rear-ended two weeks prior, and he was quite concerned about his headaches and neck pain. What compelled me to write this column was the result of a conversation I had with the insurance adjuster, which indicated to me either her poor understanding of our profession, or her company's need to establish a chiropractic policy.
When I called the adjuster to confirm the medical pay, the reported date of the accident, and other details, the adjuster asked, "Are you the doctor - or the chiropractor?"
"I am the doctor of chiropractic," I responded.
The insurance adjuster went into what sounded like a rehearsed response:
"Your patient does have med pay, but we will only pay what is medically necessary. All care is subject to medical review requiring submission of documentation to our review board consisting of chiropractors and nurses. We will not pay for any reports you submit. We only pay for care specific to the injury. If you have been treating ..."
I just had to interrupt: "First of all, let me make absolutely certain that neither you nor the company you represent are biased toward DCs. I would like to clarify: When a doctor of chiropractic performs a history and examination procedural service (generally indicated on a claims submission as a CPT code that describes an initial examination and any interim examinations, also known as 'evaluation/management' visits), do you automatically submit these to your review board for medical necessity?
"When our patients have a new complaint, or when a condition worsens, it needs evaluation and management. I am well aware that the 99080 CPT codes have components that need to be satisfied. Commonly, the report is not reimbursable unless a report is requested; furthermore, only the final examination charge is reimbursable. The report then becomes a component of the final EM code: to substantiate the medical /chiropractic necessity of the final examination."
I concluded the call with: "I would like your supervisor's name and extension, not because I will be reporting you - I am certain that you and I have a clear-cut understanding of where each of our responsibilities lie. I am curious, though, as to your company's policy and would like to provide this information to my profession."
I was later relieved to speak to the supervisor who told me: "Doctor, it is a rarity for a chiropractor not to submit adequate documentation; it appears to be a thing of the past."
Ever wonder why certain insurance companies (you know whom I mean) down-code the chiropractor's EM codes and reimburse routinely at a lower cost level? Consider what you need in your documentation. With this in mind, I present an unusual twist in a whiplash case. Recognize that examination reports need not be exhaustive; the general purpose is to simply provide "medical necessity" information on how you are managing the patient's care. Here is my letter:
Clinically Important Head Injuries
The following shall serve as a condensed review of the various types and presentations of head injuries for those in my profession. I shall review cervical conditions with my colleagues, some of whom I am certain possess far better clinical judgment than I in these entities.
When acceleration-deceleration forces are applied to the head, the brain is driven into or over sharp bony outcroppings in the skull. This can produce tissue and vascular damage, resulting in contusions or lacerations of the brain. Depending on where the contusion is, the neurological deficit may be evident. The findings will usually localize the injury near the site of the blow on the head (coup) or the opposite hemisphere (contrecoup). Frontal and temporal lobes are common sites of contrecoup contusions, as the occiput is frequently a site of injury.
This traditionally refers to loss of consciousness, however brief at the time of trauma. Concussion has been graded in levels of I-IV. For my chiropractic colleagues, grades I-II are most likely to be encountered in our clinical practices and require brief review:
This is a chronic condition of the patient who has developed healed residuals,generally three months postinjury. Postconcussion (or posttraumatic) syndrome refers to persistent headache and associated symptoms usually beginning hours to days after minor head trauma.
Associated symptoms include: sleep disorders, such as insomnia; personality changes, such as angry outbursts, fatigue, vertigo (difficult to determine because cervical facetal injury may be causative for vertigo as well); and performance inconsistencies such as impaired memory, difficulty handling multiple tasks and reduced attention spans.
Traumatic intracranial hematomas can produce such devastating neurological consequences that they must be discussed briefly. I always recommend a neurological referral if a clinical suspicion exists. (This may be dependent entirely on mechanism of trauma - do not wait for objective signs to appear!) I ask that you pay particular attention to the subdural hematoma.
Bleeding occurs when blood vessels between dura and skull are torn. These hematomas are usually produced by low-velocity blows to the head, such as those that occur in fistfights; by contrecoup arterial tears; or by lacerations occurring as the dura is pulled away from the skull by deceleration. Such injuries may or may not be associated with skull fractures. They almost always occur from a tear in the middle meningeal artery. 15-20 percent of these victims die - even with early recognition. An epidural hematoma can create a rapid increase in intracranial pressure. It is unusual that this is presented initially to a doctor of chiropractic's office.
These differ from epidurals in location, cause and prognosis. They are divided into acute, subacute, and chronic types, and are the result of venous bleeding. This takes place between dura and brain, and frequently is associated with damage to the underlying brain tissue.
An example of the cause of an acute hematoma is a high-velocity motor vehicle accident. The prognosis for this is grave, because of underlying brain injury, 50-80 percent die, even with early intervention. Subacute hematomas have a slower onset than acute, reflecting less brain damage. Their prognosis is better than grave, with a 25-percent mortality rate.
Chronic hematomas may present weeks or months after what seems a minor head injury, and may initially present to a doctor of chiropractic's office. Small vessels that bridge the subdural spaces are torn, and blood slowly accumulates in the subdural space or between layers of dura. The initial trauma may go unnoticed. Signs and symptoms include personality changes and persistent headaches. Chronic subdurals have a mortality rate of about 50 percent - almost as high as that for acute.
Hemorrhage can also occur in the brain tissue due to lacerations. Symptoms depend on the area of the brain in which bleeding occurs. Seizures are common. This can occur when decelerating head injuries drag the brain across the bony outcroppings in the skull.
Nancy Molina, DC
San Juan Capistrano, California
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