I bet you've never taken your car in for routine maintenance and had the mechanic say, "You know what, Dr. Jones, your brakes are looking bad. Let me just replace those for you - compliments of the house." That's something mechanics just don't do, unless they're a relative of yours or they owe you, big time.
I'm speaking of those chiropractors who continue to say the chiropractic equivalent of "let me take care of your brakes for free" to so many patients, in a conversation that usually starts something like this: "Your shoulder's bothering you, huh? Let's give it a look."
In case you haven't noticed, we have a proclivity to assess, diagnose and treat on the fly, with little documentation of the interaction and therefore, little possibility of getting paid. This is particularly epidemic when it comes to the patient's spontaneous admission of an extremity condition, after you've already initiated care for a separate chief complaint. This kind of patient interaction gives us warm, fuzzy feelings and a sense of pride because we can quickly problem-shoot a musculoskeletal condition for a patient and help improve their quality of life. It also wastes an opportunity to document a complaint, treat it, resolve it and get compensated for our work. It's like we're giving brake jobs away for free.
I'd like to suggest a solution that will stop us from giving away our work for free. It's one that, if implemented, could help us increase our billings for the things we already do and expand the perception of our practices within the community. Am I talking about moving from a paper practice to a digital one? Of course I am. As you know from my previous articles, I believe digital has the kinds of tools we need to break our profession's inherently bad habits and help us earn more for what we already do. Let me show you why.
Undocumented "On-the-House" Kindness Has Consequences
"On-the-house" care happens in most practices. Of course, how much and how often varies from place to place, but it's my contention that you probably run an ad hoc two-minute ortho/neuro exam on a patient extremity at least five times a week. If you don't believe me, I challenge you to start keeping track of any kind of patient interaction in which you test, assess, recommend and/or treat a patient's complaint outside of their chief complaint. Included in this challenge are modifications to activities of daily living (ADL), whereby you prescribe a change in their daily routine as a therapeutic response to their dysfunction. Take the challenge, and I'm confident you're going to recognize that this happens more than you would like to think.
So, what's the big deal about being a nice guy or gal now and again, and not being so worried about documenting every patient interaction? Let me count the ways:
- You're violating a cardinal rule of doctoring, which says never spend your own money on patient care.
- You're violating a cardinal rule of sound business, which says that the best way to make money (besides saving it) is to be adequately compensated for what you're already doing.
- While rare, you're opening yourself up to the possibility that what you might think is a simple musculoskeletal problem of the knee is actually, oh let's say, a deep venous problem that should require a medical consultation.
- You're giving the patient the impression that you're a quick analgesic to their aches and pains, not an expert in their problems. After all, experts run tests.
- Finally, you're reinforcing your own documentation bad habits, placing yourself at risk. To this last point I'll add: Undocumented patient care offers no evidence that it ever happened, essentially making it a liability, including undocumented kindness.
Why We're Giving It Away for Free
So, why aren't more chiropractors taking the time to document and bill things like E & M codes 99213 or 99212, or CPT codes for an extremity adjustment - especially when they're explicitly challenged with a new condition that's unrelated to the patient's chief complaint? The answer, of course, is in the question itself. It takes time. And time isn't what we have. Rather than see the existing patient's complaint as a justifiable reason to run a brief, problem-focused exam, complete with differential diagnosis, we find it simpler to poke, prod and adjust a fibula, and then move on to the next patient room.
There's another reason why we're not going to run a spontaneous, complete ortho/neuro exam for a new complaint: We don't have a place to do it. Most travel cards aren't big enough to make the necessary notes to fully document. There are also no prompts on most of our spine-centered documentation tools to address specific extremity complaints. If we don't feel comfortable working through a full battery of tests, and don't have the prompts to do it, then it isn't done. A patient may finally bring up the fact that they're waking up with pain and numbness in their hands over the course of the median nerve. What are the differential diagnoses for carpal tunnel syndrome? Can you remember in the rush? Out of instinct, you might think that it sounds like carpal tunnel syndrome, and find yourself adjusting a carpal or two. Instead of demonstrating your expertise on repetitive stress injuries, you're cracking bones where it hurts. Maybe it'll work, maybe it won't. Either way, the patient's perception of your knowledge hasn't been elevated by the interaction. You've just poked them where it hurts, and anybody can do that.
Bill More, Be More
What would this kind of "on-the-house" care look like in a practice that's driven by a paperless office system? Here are two different possibilities.
First, it would not be "on the house," unless the doctor wanted it to be. Instead of an undocumented secondary complaint, the doctor would have assessed, diagnosed, prescribed, documented and billed the patient. If you still want to be a nice guy or gal, then go ahead and bill the patient for your time. However, indicate what you typically charge for addressing a new complaint, and then note that the patient is getting it pro bono. That's how every other professional, be they lawyers or tax accountants, documents their generosity. It's just a little way to let their clients know their time is serious enough to cost money, even if that fee has been waved.
Second, "low back pain doctors" who might know a thing or two about the wrist or elbow, can transform themselves into musculoskeletal experts who know a whole lot more than their patients first thought. This transformation is possible because it happens in the mind of the patient, who comes from a health care cultural tradition where specialists in a particular area will never be found running ad hoc exams, making recommendations on their way from one patient room to the next.
If you're building practice success on your status as a neuromusculoskeletal expert, it makes no sense to be treating an assessment, mobilization and adjustment of the elbow as less serious than an adjustment of the lumbar spine. Yes, the local neurology is different, and the patient should be aware of that, due to your patient education. However, the impact of elbow dysfunction may be just as detrimental as their lumbar dysfunction in terms of the quality of their daily life. And they deserve to see you take both problems seriously.
Increase Your Accuracy
A third and important point: Digitally-driven, customizable exam workflow screens allow documentation to be done in seconds, allowing more accuracy in assessing spontaneous, secondary patient complaints. In the world of paper, the assessment and differential diagnosis would require sending for a new exam sheet, finding the relevant exams, performing them and reporting what was found to the patient. After the patient interaction, the patient file would be updated to start care under the new complaint, and the responsible chiropractor would be double-checking their sources to make sure the differential diagnosis was handled properly, without time to prepare a proper report of findings. The good news of this scenario is that the doctor's care would be documented and reimbursed. The bad news is that it takes a lot of time, and sets the doctor's workflow behind schedule.
In the digital clinic, a few clicks of the mouse can move any doctor through a region-centered, ortho/neuro exam, complete with differential diagnosis - in a matter of seconds to minutes. What used to take 15-30 minutes to create two pages of reimbursable quality data can now be generated in just a few minutes. The doctor can then make recommendations, suggest a treatment plan, and move on - but this time, looking more like an expert. Of course, the patient file would be automatically updated to include this new complaint.
Better Business Practices in the Digital Clinic
Utilizing the digital clinic can end your acts of violation in practicing sound business and sound doctoring wisdom. Instead, you will actually get reimbursed for those times you find yourself tempted to give away your expertise for free. My years of experience as a chiropractic clinician tell me that most of us aren't going to make the necessary changes to achieve this without the benefits found with digital documentation. It's probably the fastest way we can move from being ad hoc troubleshooters to fully documented, confident experts in spontaneous patient care. It's also the fastest way to end our poor documentation habits and elevate our image in the minds of our patients. I think it's about time chiropractors stop giving away "brake jobs" for free. We need to start being recognized and paid what we're worth. All of this is all possible in the digital clinic of the future.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.