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Practical Assessment in Orthopaedic Care Series

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Practical Assessment in Orthopaedic Care Series Practical Assessment in Orthopaedic Care Series K. Jeffrey Miller, DC, FIANM(us), MBA K. Jeffrey Miller, DC, FIANM(us), MBA Chiropractic Orthopaedist Dr. Jeff Miller is an Assistant Professor at the University of Missouri School of Medicine. He practices as a Chiropractic Physician in the Departments of Orthopaedic Surgery and Physical Medicine and Rehabilitation at The Missouri Orthopaedic Institute (MOI). Dr. Miller has been a Doctor of Chiropractic for 33 years and a chiropractic orthopedist for over 27 years. He is a prolific writer having published over 250 articles, 9 books and serves as a columnist for Dynamic Chiropractic and The Columbia Daily Tribune. A sought-after speaker in the US and abroad, Dr. Miller has presented over 300 postgraduate programs in 38 states and several countries. Practical Assessment in Orthopaedic Care Series Clinical Documentation E & M History & Examination K. Jeffrey Miller, DC, FIANM(us), MBA Pyramid of History Focus PFS ROS HPI History Component • History of the Presenting Illness – Often referred to by the abbreviation OPQRST – Onset/mechanism, palliative/provoking, quality, radiation/referral, severity, timing – CPT-E&M HPI = location, quality, severity, duration, timing, context, modifying factors and associated s/s History Component Review of Systems (ROS) – 14 Total systems based on CPT-E&M • Constitutional symptoms, • Musculoskeletal • Eyes, • Integumentary • Ears, Nose, Mouth and Throat • Neurological • Cardiovascular • Psychiatric • Respiratory • Endocrine • Gastrointestinal • Hematological/lymphatic • Genitourinary • Allergic/Immunologic History Component • Past Family, Social Histories – Surgeries/Procedures – Hospitalizations, – Immunizations, – Injuries, – Illness (short/long term) – Pregnancies – Allergies – Occupational history is included in Social History Past, Family and Social Histories (DOT Example) Documentation Statement -Mode of Onset – “A specific event or situation is not currently recognized as the causative factor.” Clinical Examination Categories Clinical Examination Categories Pyramid of History Focus What we need PFS The way we think ROS HPI Ahh…But the patients don’t know this • You know it is going to be a long visit when the patient starts the history with…”It all started 25 years ago when I…” Pyramid of History Focus Inverting what we need HPI The way the patients think ROS PFS ”It all started 25 years ago when I…” • You cannot treat “25 years ago” • You can treat “Now” • To get to the point, I Frequently try to direct the patient toward the answers to the following past history questions. – Have you had the current problem before? – When was the first time? – Has the problem been constant or intermittent? – Have you had surgery for the problem? – Have you had chiropractic care for the problem? Moving Beyond Standard History Components The Pyramid oF History Focus • The 5 Ds And 3 Ns – Let’s get to NOW – Stroke Recognition • Patient Health Survey • Questions with New Emphasis – Ten Foot Pole Patients – SuiciDe, Abuse • Daily Questions • 20 Questions – Checklist Manifesto – Prompting Information/Cooperation Miller Copyright 2002-2017 19 Patient Health Survey “Ten Foot Pole Patients” • “When you hear hoof beats think horses not zebras” • But it is the zebras you should worry about! • Rule out all the things that could kill them first! Miller Copyright 2002-2017 20 Patient Health Survey “Ten Foot Pole Patients” • Signs and symptoms of all the stuff that could turn out terrible • The form is designed for “Yes” to stick out • Also designed to catch the patients trying to skip steps/not cooperate Miller Copyright 2002-2017 21 Daily Questions Checklist Manifesto • The Checklist ManiFesto – Routine Safety Procedures • Pilots • Short day-to-day checklist example: – Pregnancy, Implanted Devices, The Ds and Ns – It is especially helpful to have a list if you provide coverage for other doctors. The same applies for new associates. – Associates, The “July Effect” Miller Copyright 2002-2017 27 Always Tell the Doctor if You • Have any concerns • Have any implanted medical devices, especially any implanted devise that is electrical, or uses a battery i.e., pacemaker, stimulator or pump. • Are or could be pregnant. • Have pain (scored 0-10) – 0 = No Pain – 10 = Terrible pain (you cannot drive, work or attend school etc.) Always Tell the Doctor if You • Have experienced changes in your symptoms – No change – Symptoms have improved – Symptoms have moved – Symptoms have increased Always Tell the Doctor if You • Have limited your activities due to your condition (changed your work, job or household activities) • Are having trouble Following home instructions • Have allergies to Latex, adhesives • Are aFraid of needles • Have been injured since your last visit Always Tell the Doctor if You • If you have seen another doctor since your last visit, and why • Are having trouble with bladder of bowel functions • Are having thoughts of suicide • Don’t feel safe at home • Are being verbally, physically or sexually abused. The Five Ds And Three Ns The 5 Ds The 3 Ns – Diplopia • Ataxia – Dizziness • Nausea – Drop Attacks • Numbness – Dysarthria • Nystagmus – Dysphagia Questions with New Emphasis Suicide, Abuse… – Suicide: (Thoughts and/or Attempts) – Abuse: Mental, Physical and/or Sexual – Smoking • Surgery – Smokers have failure rates 5x higher than non-smokers for joint surgery – 16 weeks smoke free for surgery Miller Copyright 2002-2017 35 20 Questions Prompting Information/Cooperation • I designed this to get information out of patients who are poor historians • It focuses on situations and events instead of conditions. Miller Copyright 2002-2017 36 20 + Questions • Have you ever been treated in an emergency room? – As an adult? Child? • Have you ever been transported by ambulance? • Have you ever called a doctor after hours? • Have you ever had to see a doctor while out of town? • Have you ever had emergency dental care? • Have you ever had an allergic reaction? – Food, Drug, Insect, Substance, Plants 20 Questions • Have you ever carried/do you carry medication in case of an emergency? – Nitroglycerin, Glucose, Insulin, An inhaler, Epi Pen • Have you/do you warn any type of medical alert jewelry? • Have you ever had to have a tetanus shot? • Have you ever received stiches? • Have you ever been fitted for a special brace, worn a brace or worn a cast? 20 Questions • Have you ever been admitted to a hospital? • Have you ever been anesthetized or had a body region numbed? • Do you have any implanted medical devices or embedded foreign objects from trauma (pace maker, bullets) • Have you ever been x-rayed? • Have you ever used a cane, crutches, walker, wheelchair? • Have you ever undergone a series of injections? 20 Questions • Have you ever been diagnosed as having a permanent condition? • Have you ever been disqualified from participation in any of the following: – A job – The military – A sport • Have you ever been denied medical or life insurance? 20 Questions • If I were to add to this list I would ask, “Do you have any significant or unusual scars?” Practical Assessment in Orthopedic Care Evaluation and Management Coding Changes for January 2021 K. Jeffrey Miller, DC, FIANM (us), MBA History of E & M • Prior to 1995 the time spent with the patient was the key factor in examination coding • In 1995 the key and contributing components guidelines were implemented. It was revised in 1997. After the revisions doctors could chose to use either the 1995 or 1997 guidelines. Doctors could use the guidelines that matched their field of practice. • The changes for 2021 are the first in 23 years. History of E & M • Centers for Medicare and Medicaid Services (CMS) initiated new guidelines for 2021 • The American Medical Association (AMA) became involved because it is their system and Medicare wanted to bundle some examination codes. • CMS and the AMA reached a compromise Components of Out Patient E&M Codes 3 Key Components 4 Contributing Components – History • Coordination of care – Referrals, additional tests, gathering other records etc. • HPI • Review of systems • Counseling – Report of Findings • Past, Family, Social • – Examination Nature of the illness – Brief, limited, severe • Bullets (exam procedures) • Time – Medical Decision Making – Face to face time • Degree of complication • “Doctor to Patient” Miller Copyright 2002-2017 A Change in Focus • In the current guidelines, two of the three key components, history and the exam/bullet system are the two primary focus. • The focus is changing to Medical Decision Making and Time • Despite the change in focus, History and Examnation are still vital to the process History and Examination History Categories HPI Review of systems & PFS • The standard OPQRST • 14 Systems • The foundation of every examination • Past History code, it is a part of all new patient E&M • Family History codes and most established patient E&M codes • Social History – Occupational History • There must be one HPI per complaint being addressed Miller Copyright 2002-2017 Miller Copyright 2002-2017 Miller Copyright 2002-2017 Medicare - PART Miller Copyright 2002-2017 Examination Procedures/Bullets • There have always been problems with the bullet system – I estimate that 50% of chiropractors don’t understand or use the system – Many doctors aren’t really performing the procedures. They list the required content in templates but perform only a version of what is listed. – This was one of Medicare's complaints and the reason they wanted to bundle exam codes. Examination
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